Rob Smeets

Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial

&NA; Since pain‐related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post‐treatment in a multi‐centre randomized controlled trial. In total, 85 patients suffering from disabling non‐specific CLBP reporting at least moderate pain‐related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.

Objective To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. Design Systematic review and random effects meta-analysis of randomised controlled trials. Data sources Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. Study selection criteria Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. Results Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, −0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. Conclusions Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.

Active rehabilitation for chronic low back pain: Cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial [ISRCTN22714229]

BackgroundThe treatment of non-specific chronic low back pain is often based on three different models regarding the development and maintenance of pain and especially functional limitations: the deconditioning model, the cognitive behavioral model and the biopsychosocial model.There is evidence that rehabilitation of patients with chronic low back pain is more effective than no treatment, but information is lacking about the differential effectiveness of different kinds of rehabilitation. A direct comparison of a physical, a cognitive-behavioral treatment and a combination of both has never been carried out so far.MethodsThe effectiveness of active physical, cognitive-behavioral and combined treatment for chronic non-specific low back pain compared with a waiting list control group was determined by performing a randomized controlled trial in three rehabilitation centers.Two hundred and twenty three patients were randomized, using concealed block randomization to one of the following treatments, which they attended three times a week for 10 weeks: Active Physical Treatment (APT), Cognitive-Behavioral Treatment (CBT), Combined Treatment of APT and CBT (CT), or Waiting List (WL). The outcome variables were self-reported functional limitations, patients main complaints, pain, mood, self-rated treatment effectiveness, treatment satisfaction and physical performance including walking, standing up, reaching forward, stair climbing and lifting. Assessments were carried out by blinded research assistants at baseline and immediately post-treatment. The data were analyzed using the intention-to-treat principle.ResultsFor 212 patients, data were available for analysis. After treatment, significant reductions were observed in functional limitations, patients main complaints and pain intensity for all three active treatments compared to the WL. Also, the self-rated treatment effectiveness and satisfaction appeared to be higher in the three active treatments. Several physical performance tasks improved in APT and CT but not in CBT. No clinically relevant differences were found between the CT and APT, or between CT and CBT.ConclusionAll three active treatments were effective in comparison to no treatment, but no clinically relevant differences between the combined and the single component treatments were found.

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.

Disability and quality of life in patients with fibromyalgia.

BackgroundPatients with fibromyalgia often feel disabled in the performance of daily activities. Psychological factors seem to play a pronounced disabling role in fibromyalgia.The objectives of the study are: Firstly, to investigate contributing factors for disability in fibromyalgia. Secondly, to study psychological distress in patients with fibromyalgia as compared to other nonspecific pain syndromes. And finally, to explore the impact of fibromyalgia on a patients quality of life.MethodsIn this cross sectional study, explaining factors for disability were studied based on a regression analysis with gender, mental health, physical and social functioning as independent variables. For the assessment of disability in fibromyalgia the FIQ was used. The levels of psychological distress in patients with fibromyalgia, Complex Regional Pain Syndrome (CRPS) and chronic low back pain (CLBP) were compared based on scores on the Symptom Checklist (SCL90). Quality of life of patients with fibromyalgia was compared with scores (SF36) of both patients with fibromyalgia and other health conditions as derived from the literature.ResultsDisability in fibromyalgia seemed best explained by a patients mental health condition (β = -0.360 p = 0.02). The level of psychological distress was higher in patients with fibromyalgia as compared to patients with CRPS or CLBP (p < 0.01). The impact of fibromyalgia on quality of life appeared to be high as compared to the impact of other health conditions.ConclusionPatients with fibromyalgia report a considerable impact on their quality of life and their perceived disability level seems influenced by their mental health condition. In comparison with patients with other pain conditions psychological distress is higher.

Relationship between physical activity and disability in low back pain: A systematic review and meta-analysis

&NA; It is often assumed that patients with pain‐related disability due to low back pain (LBP) will have reduced physical activity levels, but recent studies have provided results that challenge this assumption. The aim of our systematic review was to examine the relationship between physical activity and disability in LBP. The literature search included 6 electronic databases and the reference list of relevant systematic reviews and studies to May 2010. To be included, studies had to measure both disability (eg, with the Roland Morris Disability Questionnaire) and physical activity (eg, by accelerometry) in patients with non‐specific LBP. Two independent reviewers screened search results and extracted data, and authors were contacted for additional data. Correlation coefficients were pooled using the random‐effects model. The search identified 3213 records and 18 studies were eligible for inclusion. The pooled results showed a weak relationship between physical activity and disability in acute or subacute (<3 months) LBP (r = −0.08, 95% confidence interval = −0.17 to 0.002), and a moderate and negative relationship in chronic (>3 months) LBP (r = −0.33, 95% confidence interval = −0.51 to −0.15). That is, persons with acute or subacute LBP appear to vary in the levels of physical activity independent of their pain‐related disability. Persons with chronic LBP with high levels of disability are also likely to have low levels of physical activity. Persons with acute or subacute back pain appear to vary in the levels of physical activity independent of disability. Persons with chronic back pain with high levels of disability will likely have low levels of physical activity.

The Fear Avoidance Model Disentangled: Improving the Clinical Utility of the Fear Avoidance Model

BackgroundThe model of fear avoidance proposes that fear of movement in back pain patients is an obstacle to recovery and leads over time to increased disability. Therefore, fear of movement should be targeted explicitly by interventions. AimsTo review the evidence (1) for the causal components proposed by the model, and (2) about interventions that attempt to reduce fear of movement. In addition, we aim to propose alternatives and extensions to the current model in order to increase the clinical utility of the model. MethodsA collaborative narrative review. ResultsThe fear avoidance model needs to be conceptually expanded and further tested to provide adequate and appropriate clinical utility. Currently, although there is experimental support for the model, observational studies in patients show contradictory results. Interventions based on the model have not delivered convincing results, only partly due to methodological shortcomings. Some assumptions inherent in the current model need adjusting, and other factors should be incorporated to indicate subgroupings within patients high in avoidance behavior. In addition, both theoretical and methodological limitations were identified in measurements of fear and avoidance. ConclusionsFuture research should elucidate whether the proposed subgrouping of patients with avoidance behavior is helpful. Further research should focus on developing more accurate and psychometrically sound assessment tools as well as targeted interventions to improve activities and participation of patients with chronic disabling musculoskeletal pain disorders.

Do patients with chronic low back pain have a lower level of aerobic fitness than healthy controls?: are pain, disability, fear of injury, working status, or level of leisure time activity associated with the difference in aerobic fitness level?

Study Design. Prospective case series with historical controls (normative data). Objectives. To compare the aerobic fitness level of patients with chronic low back pain (CLBP) with healthy controls matched for gender, age, and level of sport activity and to evaluate the association of the difference in aerobic fitness level with pain intensity, duration and degree of disability, fear of injury, and level of activity during work, including household and leisure time. Summary and Background Data. Controversy exists whether patients with CLBP have a lower level of aerobic fitness and whether this level may partly depend on the patients’ activity level. Methods. A total of 108 CLBP patients completed questionnaires regarding pain, disability, fear of injury, and activity level and performed a modified Åstrand submaximal cycling test. The maximum oxygen consumption (VO2max) was calculated and compared with normative data. Multiple linear regression analysis was performed with the difference of the level of aerobic fitness as dependent variable. Results. VO2max could be calculated in 78% of the patients. Both men and women with CLBP had significant lower VO2max than the healthy referents (10 mL/kg LBM • min−1 and 5.6 mL/kg LBM • min−1 respectively, P < 0.001), and this difference was significantly greater in men (P = 0.03). Multiple regression analysis showed that the level of aerobic fitness was not associated with the presumed variables. The patients who stopped the test prematurely were older (P = 0.02) and more disabled (P = 0.01). Conclusion. CLBP patients, especially men, seem to have a reduced aerobic fitness level compared with the normative population. No explanatory factor for that loss could be identified.

Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review

Background Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. Purpose The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. Data Sources Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0–10). Study Selection Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. Data Extraction Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. Results are presented as weighted mean differences with 95% confidence intervals. Data Synthesis Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3–9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were −6.2 (−9.4 to −3.0), −5.5 (−9.9 to −1.0), −6.5 (−10.1 to −3.0), and −3.9 (−7.4 to −0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Limitations Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. Conclusions The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees

OBJECTIVE To determine the prevalence of osteoarthritis (OA) in the knee and/or hip of the intact leg among traumatic leg amputees compared with the general population and its relationship with amputation level, time since amputation, age, and mobility. DESIGN Cross-sectional observational study. SETTING Outpatient population of 2 Dutch rehabilitation centers. PARTICIPANTS Patients (N=78) with a unilateral traumatic transtibial amputation, knee disarticulation, or transfemoral amputation of at least 5 years ago; ability to walk with a prosthesis; older than 18 years of age; and able to understand Dutch. Patients were excluded if they had bilateral amputations, other pathologies of the knee or hip, or central neurologic pathologies. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The prevalence of OA. RESULTS The prevalence of knee OA was 27% (men 28.3%, women 22.2%) and hip OA was 14% (men 15.3%, women 11.1%). This was higher compared with the general population (knee OA men 1.58%, women 1.33%, hip OA men 1.13%, women 0.98%, age adjusted). No significant relationships between the prevalence of OA and level of amputation, time since amputation, mobility, and age were found. CONCLUSIONS The prevalence of OA is significantly greater for both the knee and hip in the traumatic leg amputee population. No specific risk factors were identified. Although no specific risk factors in this specific population could be identified, it might be relevant to apply commonly known strategies to prevent OA as soon as possible after the amputation.