Silje Endresen Reme

Prevalence of psychiatric disorders in sick listed chronic low back pain patients

Background: Previous findings have shown a high degree of comorbid psychopathology in chronic low back pain (CLBP), but less is known about the broad range of comorbid psychiatric disorders. The prevalence is reported to be between 40% and 100% depending on methods being used, sample or setting.

Expectations, perceptions, and physiotherapy predict prolonged sick leave in subacute low back pain

BackgroundBrief intervention programs for subacute low back pain (LBP) result in significant reduction of sick leave compared to treatment as usual. Although effective, a substantial proportion of the patients do not return to work. This study investigates predictors of return to work in LBP patients participating in a randomized controlled trial comparing a brief intervention program (BI) with BI and physical exercise.MethodsPredictors for not returning to work was examined in 246 patients sick listed 8-12 weeks for low back pain. The patients had participated in a randomized controlled trial, with BI (n = 122) and BI + physical exercise (n = 124). There were no significant differences between the two intervention groups on return to work. The groups were therefore merged in the analyses of predictors. Multiple logistic regression analysis was used to identify predictors for non return to work at 3, 12, and 24 months of follow-up.ResultsAt 3 months of follow-up, the strongest predictors for not returning to work were pain intensity while resting (OR = 5.6; CI = 1.7-19), the perception of constant back strain when working (OR = 4.1; CI = 1.5-12), negative expectations for return to work (OR = 4.2; CI = 1.7-10), and having been to a physiotherapist prior to participation in the trial (OR = 3.3; CI = 1.3-8.3). At 12 months, perceived reduced ability to walk far due to the complaints (OR = 2.6; CI = 1.3-5.4), pain during activities (OR = 2.4; CI = 1.1-5.1), and having been to a physiotherapist prior to participation in the trial (OR = 2.1; CI = 1.1-4.3) were the strongest predictors for non return to work. At 24 months age below 41 years (OR = 2.9; CI = 1.4-6.0) was the only significant predictor for non return to work.ConclusionIt appears that return to work is highly dependant on individual and cognitive factors. Patients not returning to work after the interventions were characterized by negative expectations, perceptions about pain and disability, and previous physiotherapy treatment. This is the first study reporting that previous treatment by physiotherapists is a risk factor for long-term sick leave. This has not been reported before and is an interesting finding that deserves more scrutiny.

Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain

Purpose The aim of this study is to provide a narrative review of the current state of knowledge of the role of cognitive behavioral therapy (CBT) in the management of chronic nonspecific back pain. Methods A literature search on all studies published up until July 2012 (PubMed and PsycINFO) was performed. The search string consisted of 4 steps: cognitive behavioral therapy/treatment/management/modification/intervention, chronic, back pain (MeSH term) or low back pain (MeSH term), and randomized controlled trial (MeSH term). The conclusions are based on the results from randomized controlled trials (RCTs) and reviews of RCTs. Interventions were not required to be pure CBT interventions, but were required to include both cognitive and behavioral components. Results The search yielded 108 studies, with 46 included in the analysis. Eligible intervention studies were categorized as CBT compared to wait-list controls/treatment as usual, physical treatments/exercise, information/education, biofeedback, operant behavioral treatment, lumbar spinal fusion surgery, and relaxation training. The results showed that CBT is a beneficial treatment for chronic back pain on a wide range of relevant variables, especially when compared to wait-list controls/treatment as usual. With regards to the other comparison treatments, results were mixed and inconclusive. Conclusion The results of this review suggest that CBT is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments. Multidisciplinary and transdisciplinary interventions that integrate CBT with other approaches may represent the future direction of management of chronic back pain, with treatments modified for specific circumstances and stakeholders. There is a need for future intervention studies to be specific in their use of cognitive behavioral elements, in order for results to be comparable.

Work-focused cognitive-behavioural therapy and individual job support to increase work participation in common mental disorders: a randomised controlled multicentre trial.

Objectives Common mental disorders (CMDs) are a major cause of rising disability benefit expenditures. We urgently need evidence on programmes that can increase work participation in CMDs. The aim of this study was to evaluate the effectiveness of work-focused cognitive–behavioural therapy (CBT) and individual job support for people struggling with work participation due to CMDs. Methods A randomised controlled multicentre trial (RCT) including 1193 participants was conducted. Participants were on sick leave, at risk of going on sick leave or on long-term benefits. The intervention integrated work-focused CBT with individual job support. The control group received usual care. The main outcome was objectively ascertained work participation at 12 months follow-up, with changes in mental health and health-related quality of life as secondary outcomes. Results A larger proportion of participants in the intervention group had increased or maintained their work participation at follow-up compared to the control group (44.2% vs 37.2%, p=0.015). The difference remained significant after 18 months (difference 7.8%, p=0.018), and was even stronger for those on long-term benefits (difference 12.2%, p=0.007). The intervention also reduced depression (t=3.23, p≤0.001) and anxiety symptoms (t=2.52, p=0.012) and increased health-related quality of life (t=2.24, p=0.026) more than usual care. Conclusions A work-focused CBT and individual job support was more effective than usual care in increasing or maintaining work participation for people with CMDs. The effects were profound for people on long-term benefits. This is the first large-scale RCT to demonstrate an effect of a behavioural intervention on work participation for the large group of workers with CMDs. Trial registration number ClinicalTrials.gov, registration number: NCT01146730.

Therapist effects in routine psychotherapy practice: An account from chronic fatigue syndrome

Abstract The effect of therapists in psychotherapy is a much debated topic, with a number of studies showing therapist variance being large while other studies show little or no variability in outcomes due to therapists. The aim of this study was to investigate therapist effects in a well-defined sample of patients and therapists from an outpatient service which specializes in providing cognitive behaviour therapy (CBT) for patients with chronic fatigue syndrome (CFS). Therapy was provided in a highly specialized clinical setting for CFS and was delivered by qualified CBT therapists with at least 2 years experience with this client group. Three hundred and seventy-four patients with CFS and 12 cognitive behavioural psychotherapists took part. Therapist effects on the primary outcomes of fatigue and disability were investigated with multilevel random effects models and variance component analysis. Different models were computed and compared. Results showed a reduction in fatigue and disability scores after therapy. Variance explained by therapists, when demographic covariates were accounted for, was 0% for fatigue and under 2% for disability. A number of important factors may have played a significant role in minimizing therapist effects in our study. These are: specialist setting, single centre, patients with the same primary diagnosis, therapists of the same orientation and training, shared environment and supervision. Future studies may stress the importance of these factors in the investigation of the therapist effect in psychotherapy.

Predictors of treatment outcome after cognitive behavior therapy and antispasmodic treatment for patients with irritable bowel syndrome in primary care

OBJECTIVE To examine predictors of treatment outcome in IBS-patients who participated in a randomized controlled trial in primary care, where 149 irritable bowel syndrome (IBS) patients were randomized to mebeverine hydrochloride (n=77) or mebeverine+cognitive behavior therapy (CBT) (n=72). CBT offered additional benefit over mebeverine alone. METHODS Regression analyses were used to identify predictors of work and social adjustment 12 months after treatment ended. The intervention groups were analyzed separately in order to look at the separate effects in each group. RESULTS Lower levels of psychological distress (anxiety and depression) at baseline predicted a good outcome in the mebeverine group [beta=0.388 (95% CI: 0.065-0.936), P=.025] but not in the mebeverine+CBT group. In the adjusted model for the mebeverine+CBT group less adaptive IBS related behavioral coping predicted a good outcome [beta=0.285 (95% CI: 0.002-0.210), P=.045]. CONCLUSION Different factors are associated with outcome depending on the treatment received. At assessment clinicians should assess patients coping styles and may want to consider recommending CBT to those patients with IBS in primary care who are engaging in unhelpful coping behavior.

Work-Family Conflict, Psychological Distress and Sleep Deficiency Among Patient Care Workers

This study examined whether work-family conflict was associated with sleep deficiencies, both cross-sectionally and longitudinally. In this two-phase study, a workplace health survey was completed by a cohort of patient care workers (n = 1,572). Additional data were collected 2 years later from a subsample of the original respondents (n = 102). Self-reported measures included work-family conflict, workplace factors, and sleep outcomes. The participants were 90% women, with a mean age of 41 ± 11.7 years. At baseline, after adjusting for covariates, higher levels of work-family conflict were significantly associated with sleep deficiency. Higher levels of work-family conflict also predicted sleep insufficiency nearly 2 years later. The first study to determine the predictive association between work-family conflict and sleep deficiency suggests that future sleep interventions should include a specific focus on work-family conflict.

The development of the irritable bowel syndrome-behavioral responses questionnaire.

OBJECTIVE Unhelpful behavior related to irritable bowel syndrome (IBS) is often targeted and expected to change in treatments such as cognitive behavioral therapies. However, no scale has previously been produced to assess these dimensions. The aim of this study was to develop and validate an IBS-specific behavioral responses questionnaire. METHODS A total of 153 patients with IBS as diagnosed by a general practitioner completed the 28-item Irritable Bowel Syndrome-Behavioral Responses Questionnaire (IBS-BRQ). A total of 117 persons without IBS also completed the IBS-BRQ and were used as a control group. Tests of internal consistency and principal components analyses (PCAs) were performed on both sets of data. RESULTS The scale was found to be both reliable and valid with a high degree of internal consistency for both IBS patients (Cronbachs alpha=.86) and controls (Cronbachs alpha=.89). The scale differentiated significantly between IBS patients and controls (F=221, P<.01). The PCA supported a two-factor solution in both sets of data. Two items were removed from the scale due to low discriminative ability. The criterion validity was high as evidenced by a strong correlation with the Cognitive Scale for Functional Bowel Disorders (CS-FBD) (r =.67, P<.001). CONCLUSION The IBS-BRQ is a valid and reliable scale that can be used for clinical as well as empirical purposes.

Association Between Illness Perceptions and Return-to-Work Expectations in Workers with Common Mental Health Symptoms

Purpose Mental health symptoms (MHSs) may affect people’s work capacity and lead to sickness absence and disability. Expectations and perceptions of illness have been shown to influence return to work (RTW) across health conditions, but we know little about illness perceptions and RTW-expectations in MHSs. The aim of this study was to investigate the association between illness perceptions and RTW-expectations in a group struggling with work participation due to MHSs. Methods Cross-sectional associations between illness perceptions and return to work expectations at baseline were analyzed for 1,193 participants who reported that MHSs affected their work participation. The study was part of a randomized controlled trial evaluating the effect of job focused Cognitive Behavioral Therapy (CBT) combined with supported employment (IPS). Participants were from a working age population with diverse job status. Results There was a strong and salient relationship between illness perceptions and RTW-expectations. When adjusting for demographic and clinical variables, the components consequences, personal control, identity and illness concern remained significantly associated with uncertain and negative RTW-expectations. Less illness understanding remained significantly associated with uncertain RTW-expectations, while timeline and emotional representations remained significantly associated with negative RTW-expectations. In the fully adjusted model only the consequences component (believing that illness has more severe consequences) remained significantly associated with RTW-expectations. Openly asked, participants reported work, personal relationships and stress as main causes of their illness. Conclusions In people with MHSs who struggle with work participation, perceptions and beliefs about their problems are strongly associated with their expectations to return to work.

The Pain Recovery Inventory of Concerns and Expectations A Psychosocial Screening Instrument to Identify Intervention Needs Among Patients at Elevated Risk of Back Disability

Objective: To reduce a full psychosocial test battery to a brief screening questionnaire to triage return-to-work strategies among patients with low back pain (LBP). Methods: Workers (N = 496) with acute, work-related LBP completed multiple psychosocial measures at intake, then a 3-month follow-up of pain, function, and work status. A sensitivity analysis was conducted to reduce the number of items while maintaining scale reliability, preserving associations with outcomes, and maintaining separation between patient subgroups. Results: The pool of items was trimmed from 129 to 46 items, describing elements of emotional distress, pain beliefs, organizational support, and activity limitation. A confirmatory cluster analysis replicated previous findings of three risk subgroups: distressed, avoidant, and lacking employer support. Conclusions: The reduced measure is a reliable and valid screening measure that can be used to identify early intervention needs among working adults with LBP.