How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury
BACKGROUND: Expecting to recover from a musculoskeletal injury is associated with actual recovery. Expectations are potentially modifiable, although it is not well understood how injured persons formulate expectations. A better understanding of this may lead to better knowledge about how interventions might be implemented, what to intervene on and when to intervene. OBJECTIVES: The objectives of this study were to explore what 'recovery' meant to participants, whether they expected to 'recover', and how they formed these expectations. METHODS: This qualitative study used interpretive phenomenological analysis. Eighteen semi-structured interviews were conducted with persons seeking treatment for recent musculoskeletal injuries. RESULTS: Recovery was conceptualized as either complete cessation of symptoms/pain-free return to function or return to function despite residual symptoms. Expectations were driven by desire for a clear diagnosis; belief (or disbelief) in the clinician's prognosis; prior experiences; others' experiences and attitudes; information from other sources such as the internet; and a sense of self as resilient. CONCLUSIONS: Expectations appear to be embedded in both hopes and fears suggesting that clinicians should address both when negotiating realistic goals and educating patients. This is particularly relevant for cases of non-specific musculoskeletal pain where diagnoses are unclear and treatment may not completely alleviate pain.
A conservative care approach to the rehabilitation of patients with spine pain
New Delhi : Jaypee Brothers, 2015
Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review
BACKGROUND CONTEXT: Psychological factors are believed to influence the development of chronic low back pain. To date, it is not known how fear-avoidance beliefs (FABs) influence the treatment efficacy in low back pain. PURPOSE: To summarize the evidence examining the influence of FABs measured with the Fear-Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobia on treatment outcomes in patients with low back pain. STUDY DESIGN/SETTING: This is a systematic review. PATIENT SAMPLE: Patients with low back pain. OUTCOME MEASURES: Work-related outcomes and perceived measures including return to work, pain, and disability. METHODS: In January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating nonoperative treatment efficacy. Out of 646 records, 78 articles were assessed in full text and 17 RCTs were included. Study quality was high in five studies and moderate in 12 studies. RESULTS: In patients with low back pain of up to 6 months duration, high FABs were associated with more pain and/or disability (4 RCTs) and less return to work (3 RCTs) (GRADE high-quality evidence, 831 patients vs. 322 in nonpredictive studies). A decrease in FAB values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, 2 RCTs with moderate quality, 242 patients). Interventions that addressed FABs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1,051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline FABs to be associated with more pain and disability and less return to work (339 patients), whereas 3 others (832 patients) found none (GRADE low evidence). Heterogeneity of the studies impeded a pooling of the results. CONCLUSIONS: Evidence suggests that FABs are associated with poor treatment outcome in patients with LBP of less than 6 months, and thus early treatment, including interventions to reduce FABs, may avoid delayed recovery and chronicity. Patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.
Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review
BACKGROUND CONTEXT: Psychological factors including catastrophizing thoughts are believed to influence the development of chronic low back pain (LBP). PURPOSE: To assess the prognostic importance of catastrophizing as a coping strategy in patients with LBP. STUDY DESIGN: This is a systematic review. PATIENT SAMPLE: This study included patients with LBP. OUTCOME MEASURES: Work-related outcomes and perceived measures including return to work, pain, and disability. METHODS: In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, Medline, Scopus, and Web of Science. To ensure completeness of the search, a hand search and a search of bibliographies were conducted and all relevant references included. All observational studies investigating the prognostic value of catastrophizing in patients with LBP were eligible. Included were studies with 100 and more patients and follow-up of at least 3 months. Excluded were studies with poor methodological quality, short follow-up duration, and small sample size. RESULTS: A total of 1,473 references were retrieved, and 706 references remained after the removal of duplicates. For 77 references, the full text was assessed and 19 publications based on 16 studies were included. Of four studies that investigated work-related outcomes, two found catastrophizing to be associated with work status. Most studies that investigated self-reported outcome measures (n=8, 66%) found catastrophizing to be associated with pain and disability at follow-up in acute, subacute, and chronic LBP patients. In most studies that applied cutoff values, patients identified as high catastrophizers experienced a worse outcome compared with low catastrophizers (n=5, 83%). CONCLUSIONS: There is some evidence that catastrophizing as a coping strategy might lead to delayed recovery. The influence of catastrophizing in patients with LBP is not fully established and should be further investigated. Of particular importance is the establishment of cutoff levels for identifying patients at risk.
The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review
BACKGROUND CONTEXT: Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP). PURPOSE: The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP. DESIGN/SETTING: The design of this study was a systematic review. METHODS: In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis. RESULTS: The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive. CONCLUSIONS: Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.
Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review
STUDY DESIGN: Systematic review. OBJECTIVE: The aim of this study was to assess the effect of catastrophizing on treatment efficacy and outcome in patients treated for low back pain. SUMMARY OF BACKGROUND DATA: Psychological factors including catastrophizing thoughts are thought to increase the risk for chronic low back pain. The influence of catastrophizing is debated. METHODS: In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, EMBASE, OTseeker, PeDRO, PsycINFO, MEDLINE, Scopus, and Web of Science. For 50 of 706 references, full text was assessed. Results based on 11 studies were included in this analysis. RESULTS: In the 11 studies, a total of 2269 patients were included. Seven studies were of good and 4 of moderate methodological quality. Heterogeneity in study settings, treatments, outcomes, and patient populations impeded meta-analysis. Catastrophizing at baseline was predictive for disability at follow-up in 4 studies and for pain in 2 studies. Three studies found no predictive effect of catastrophizing. A mediating effect was found in all studies (n = 5) assessing the impact of a decrease in catastrophizing during treatment. A greater decrease was associated with better outcome. Most studies that investigated the moderating effects on treatment efficacy found no effect (n = 5). However, most studies did not look for a direct interaction between the treatment and catastrophizing thoughts. No study investigated the influence of catastrophizing on work-related outcomes including return to work. CONCLUSION: Catastrophizing predicted degree of pain and disability and mediated treatment efficacy in most studies. The presence of catastrophizing should be considered in patients with persisting back pain. Limited evidence was found for the moderating effects on treatment efficacy. Future research should aim to clarify the role of catastrophizing as a moderator of outcome and investigate its importance for work-related outcomes.Level of Evidence: 1.
Identifying determinants of low back pain behaviors [Meeting Abstract]
BACKGROUND CONTEXT: Nonspecific low back pain (LBP) remains a large public health problem despite attempts to minimize its impact. Evidence- based guidelines (EBG) are well defined and their efficacy demonstrated, yet clinical adherence is inconsistent. Various explanations for non-adherence to the evidence include clinician beliefs that guidelines are incongruent with patient expectations and clinician desire to satisfy patients' request for non-guideline care. PURPOSE: This study systematically explored the low back pain literature to synthesize what is known about patient expectations of care, and investigated the knowledge, beliefs and attitudes of patients with LBP regarding seeking care and how they use this information to guide their health care choices. The purpose was to explore patient perceptions on topics related to LBP including natural history, red flags, management, and attitudes about patient-clinician shared decision making. STUDY DESIGN/SETTING: This pilot study is a mixed methods design combining a systematic review with qualitative study design. Subjects were recruited at the New York University Langone Medical Center (NYULMC) Spine Center. PATIENT SAMPLE: Ten adult volunteer subjects with recurrent chronic LBP seeking care from a spine specialist were recruited at the NYULMC Spine Center. OUTCOME MEASURES: Domains related to patient attitudes and beliefs, and their impact on health care consumption for managing LBP were extracted from the admissible evidence. These domains were then compared with coded and synthesized interview data to either support or refute the patient narrative. METHODS: Literature review: A systematic literature search was performed with a NYULMC clinical librarian. Two researchers systematically screened the references using pre-defined inclusion-exclusion criteria. Structured interviews: Subjects with recurrent chronic LBP were recruited for a semi structured interview developed by a multidisciplinary team of LBP experts. Themes were extracted using !
Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain
BACKGROUND CONTEXT: Musculoskeletal disorders of the spine in the US military account for the single largest proportion of the absence of sickness causes leading to early termination. We explored if selected psychological and physical factors were associated with poor outcome after episodes of low back pain (LBP). PURPOSE: To identify clinical, demographic, and psychological factors predictive of work duty status after a complaint of LBP. STUDY DESIGN: A prospective clinical cohort of US Navy personnel treated for LBP. PATIENT SAMPLE: Eligible cases were active duty US Navy or Marine Corps personnel presenting to an emergency clinic or primary care clinic with a complaint of LBP, where the index episode of LBP was no more than 12 weeks duration before enrollment. OUTCOME MEASURES: The subject's work status (full duty, light duty, sick in quarters [SIQ], limited duty, or medically released to full duty) was abstracted from the subject's electronic medical record at approximately 4 weeks and then again 12 weeks after study enrollment. Work status in this study population is assigned by a Navy health-care provider at the time of a clinical visit and based on the health-care provider's determination of medical fitness for duty. This study collapsed work status into two groups, "full duty" (consisting of "full duty" and "medically released to full duty") and "not at full duty" (consisting of "light duty," "SIQ," and "limited duty"). METHODS: Volunteers completed a baseline questionnaire consisting of recommended well-validated measures, including attitudes and beliefs about LBP and work (Fear-Avoidance Beliefs Questionnaire [FABQ] and the Tampa Scale of Kinesiophobia), distress (the Pain Catastrophizing Scale), clinical depression (The Center for Epidemiologic Studies Depression scale), a numeric pain intensity scale, self-perceived disability (Oswestry Disability Index), and general health status (12-Item Short Form Health Survey). Navy health-care providers conducted a back pain-specific medical evaluation. Associations are expressed as multivariate-adjusted prevalence ratios (PRs) estimated using Poisson regression. RESULTS: Two hundred fifty-three participants were enrolled. Work status outcome was collected for 239 participants. Predictors of "not at full duty" at 4 weeks after enrollment included having back pain for 4 weeks or less before study enrollment (PR, 2.69; 95% CI, 1.21-5.97) and increased FABQ Work subscale score (PR, 1.05; 95% CI, 1.01-1.08). The sole predictor of work status at 12 weeks after enrollment was increased FABQ Physical Activity (FABQ Physical) subscale score (PR=1.14; 95% CI, 1.00-1.30). CONCLUSIONS: The findings that fear-avoidance beliefs were predictive of subsequent work status among active duty service personnel in this study population (after adjusting for clinical, demographic, and psychological covariates) suggest the clinical utility of addressing these factors during treatment of back pain episodes in the military. These findings reflect the important role that psychological factors may play in the return to work process in an active duty military population.
Implementation of a multidisciplinary program for active duty personnel seeking care for low back pain in a U.S. Navy Medical Center: a feasibility study
The aim of the pilot study was to evaluate a multidisciplinary program for nonspecific low back pain (NSLBP) at a major U.S. Navy base. In this single blinded randomized clinical trial, subjects were drawn from a larger, prospective cohort of active duty service members seeking care for NSLBP pain at a U.S. Navy Branch Medical Clinic. Outcome measures included return to work, self-reported pain, function, and psychological distress. Subjects were randomly allocated to one of two study arms: a multidisciplinary reconditioning program or the current standard of care for low back pain. The intervention lasted 4 weeks with a 12-week follow-up. Thirty-three subjects were enrolled. Subjects allocated to multidisciplinary care reported significantly lower perceived disability (p = 0.014) and less pain than those allocated to usual care at the end of the intervention period. All subjects returned to their usual duty following the conclusion of the intervention. The implementation of the intervention program was successful. Subjects in the multidisciplinary program showed a clinically significant improvement in the perception of disability compared to the usual care group. This is an important finding since perception of disability is associated with long-term functional outcome.
Managing nonspecific low back pain: do nonclinical patient characteristics matter?
STUDY DESIGN.: A fully blocked experimental design using clinical vignettes to query primary care physicians on prescription for management of acute nonspecific low back pain. OBJECTIVE.: To identify how nonclinical patient factors, specifically sex, patient presentation, and socioeconomic status, influence physician treatment recommendations for assessing and treating acute nonspecific low back pain. SUMMARY OF BACKGROUND DATA.: Adherence to evidence-based practice guidelines for nonspecific low back pain remains inconsistent. Therefore, it is important to understand what factors guide physician management of these cases. METHODS.: One vignette and questionnaire was distributed to primary care and emergency department clinical physicians during meetings at five teaching hospitals. The questionnaire asked for diagnostic and treatment recommendations including specific tests, medications, therapeutic procedures, activity, referral to other services, and patient education for the case represented in the vignette. RESULTS.: Subjects included 284 physicians and approximately 75% had less than 5 years of clinical practice experience. Multivariate logistic regression showed seven significant associations of patient factors with treatment recommendations for acute nonspecific low back pain (one sex, two socioeconomic status, and four patient presentation; P < 0.05). CONCLUSION.: All three assessed nonclinical factors influenced physician decisions regarding diagnostic and treatment recommendations for acute nonspecific low back pain. Patient presentation, suggestive of a patient's emotional state, was shown to be the most influential