Content uploaded by Kieran O'Sullivan
Author content
All content in this area was uploaded by Kieran O'Sullivan on Nov 23, 2015
Content may be subject to copyright.
Cognitive Functional Therapy for Disabling, Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study
Abstract
Multiple dimensions across the biopsychosocial spectrum are relevant in the management of non-specific chronic low back pain (NSCLBP). Cognitive functional therapy is a behaviourally targeted intervention which combines normalisation of movement and abolition of pain behaviours with cognitive reconceptualisation of the NSCLBP problem, while also targeting psychosocial and lifestyle barriers to recovery.
To examine the effectiveness of cognitive functional therapy for people with disabling NSCLBP who are awaiting an appointment with a specialist medical consultant.
A multiple case (n=26) cohort study consisting of 3 phases (A1-B-A2).
Measurement phase A1 was a baseline phase during which pain and functional disability were collected on three occasions over three months for all participants. During phase B, participants entered a cognitive functional therapy intervention program, involving approximately eight treatments over an average of 12 weeks. Finally, phase A2 was a 12 month no-treatment follow-up period. Outcomes were analysed using repeated measures ANOVA or Friedman's test (with post-hoc Bonferroni) across seven time intervals, depending on normality of data distribution.
Statistically significant improvements in both functional disability (p<0.001) and pain (p<0.001) were observed immediately post-intervention, and maintained over the 12 months follow-up period. These reductions reached clinical significance for both disability and pain. Secondary psychosocial outcomes were significantly (p<0.01) improved after the intervention, including depression, anxiety, back beliefs, fear of physical activity, catastrophising and self-efficacy.
Not a randomised controlled trial. While primary outcome data was self-reported, the assessor was not blinded.
These promising results suggest that cognitive functional therapy should be compared to other conservative interventions for the management of disabling NSCLBP in secondary care settings in large randomised clinical trials.
© 2015 American Physical Therapy Association.
... nine (42.9%), and 11 studies (52.4%) were scored negatively respectively (see Table 3 summary). Of 11 studies with a zero rating for statistical power (item 27), five were underpowered [36,40,42,46,48], whilst it was unclear/undetermined for the remaining six [35,41,[50][51][52][53]. By implication, the between-group results may be understated, since four of 15 comparative studies (3 RCTs and 1 CCT) [35,41,42,48] reporting non-significant differences between groups were Studies included in synthesis (n = 21) Global estimates for LBP were extrapolated to create a rudimentary set of criteria to assess external validity (item 11) and uniformly applied to each study's sample. ...
... LBP is typically more common in females, but these differences appear to diminish once chronicity is accounted for [56] whilst age-related LBP prevalence is generally negatively skewed and reported to be highest between 40 to 69 years [4] whilst global LBP prevalence reportedly peaks around 80 years old [57]. Accordingly, nine studies [36,38,41,44,46,47,50,52,54] scored '1' for satisfying both conditions: (i) the proportion of females is higher but less than 60% overall; and (ii) the mean/ median age falls within the range of 40.00 to 63.5 years (but 10 and 17 studies satisfied one condition respectively -see Additional file 1: Item 11 scoring grid Results S1). Since comorbid and/or confounding conditions (e.g., age restrictions, pregnancy, neurological, rheumatological, cancer, fractures, recent surgery) were generally excluded, these samples are fairly homogenous since their inclusion-exclusion criteria were comparable, but older patients were typically excluded. ...
... Twenty-one studies (N = 3075 participants) with a wide range of research designs were included in the review; specifically, 12 randomised clinical trials (RCTs; n = 1064 [35][36][37][38][39][40][42][43][44][45][46]; n = 255 cluster-randomised [41]), three non-randomised, controlled clinical trials (CCTs; n = 460) [47][48][49], four observational cohort studies (n = 1220) [52][53][54][55], one case series (n = 50) [51], and one interrupted time series (n = 26) [50]. RCT sample sizes ranged from 38 (pilot [42]) to 222 (3-armed trial [44]) patients. ...
Background and objective
Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning.
Databases and data treatment
Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach.
Results
Twenty-one primary studies ( N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.
Conclusion
This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.
... In a multiple casecohort study, researchers showed that CFT significantly improved pain, disability, and psychological outcomes. However, the authors recommended comparing CFT with other conservative interventions for the management of CNSLBP in larger RCTs [19]. ...
... Cognitive functional therapy was prescribed for each patient in CFT group based the CFT protocol conducted by O'Sullivan et al. (2015) [19,33]. Patients received supervised 12 sessions of training over the 8-week period with 60 min per session provided with another physical therapist who had been trained in CFT treatment. ...
Background
This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).
Methods
In a single-blind randomized clinical trial, we randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). We evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. We used mixed-model ANOVA to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.
Results
CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.
Conclusion
This study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.
Trial registration
The researchers retrospectively registered the trial 10/11/2022, at https://www.umin.ac.jp/ with identifier number (UMIN000047455).
... Am Ende der ersten Sitzung sollte eine starke therapeutische Allianz durch eine empathische und validierende Kommunikation aufgebaut worden sein (6). (12,5). ...
... • Die CFT-Intervention wird in den Studien von sehr erfahrenen erapeuten mit teils über 13 Jahren Erfahrung in der muskuloskelettalen Physiotherapie durchgeführt (12). Wie ist der Übertrag für Berufsanfänger, die eine Fortbildung in diesem Bereich besuchen? ...
Chronic pain is a multidimensional construct with an individual manifestation of biological, psychological and social factors. Multimodal pain management programs are rare and costintensive but the most powerful treatment at the present time. CFT could give physiotherapists the opportunity to address these various factors in the context of primary care following current guidelines. The concept consists of a patient centered pain education combined with exposure therapy and lifestyle changes. The aim of this paper is to explore the effectiveness of CFT regarding reduction of pain and disability in comparison to other multidimensional care programs. Two randomized controlled trials show that there is a statistical and clinical significant reduction for disability in comparison to other combined programs. It seems likely that physiotherapists can provide a behavioral cognitive treatment with an additional training. For long-term consequences in the daily practice, an entire team should join the seminar to support each other. There remains the question how CFT should be delivered for the optimal learning process. Short treatment periods could be a barrier for implementing this concept. Questionnaires could facilitate the first appointment when the patient fill the documents before the treatment begins.
... The approach centers on the retraining of maladaptive movement patterns, reconceptualizing patient pain beliefs, and addressing any relevant cognitive, psychological, social or lifestyle factors [21]. It combines a functional behavioral approach of normalizing provocative postures and movements while discouraging pain behaviors, with cognitive reconceptualization of the NSCLBP problem [31]. ...
The biomedical approaches managing low back pain have led to an exponential increase in health-care costs, with a concurrent increase in disability and chronicity, due to the lack of person-centred management and the failure to adopt a biopsychosocial framework based on contemporary evidence. The need of potential treatments to take the complexity of low back pain into account and encompass a representative range of medical disciplines and disciplines allied to medicine, combined so as to offer maximum benefit to patients has emerged. Cognitive Functional therapy is a multidimensional, patient-centred intervention that directly explores and manages cognitive, psychological and social factors deemed to be barriers to recovery in chronic low back pain. This review presents a new treatment method of chronic low back pain, cognitive functional therapy and describe the principals of this approach. This approach could potentially help physiotherapists who seek to treat chronic low back pain in a more multidisciplinary way.
... In studies related to chronic backache, it is seen that the participants' body mass index (BMI) averages are at the level of obesity 37,38 . In our study, our participants consist of 1st-degree obese individuals as in the literature. ...
Introduction. This study aims to investigate the effects of Kinesio banding on backache and flexibility in addition to exercise therapy for sedentary women with chronic mechanical backache. Material and methods. A total of 20 sedentary women participated in the study voluntarily. The women in the subject group were applied both Kinesio band and exercise, while the control group was applied only the same exercise program as the subject group. Results. The results of statistical analysis revealed that exercise and Kinesio banding created a more positive difference in flexibility and backache values in the subject group compared to the control group (p <0.05). It was determined that the application of the Kinesio band applied together with exercise is a more effective method in sedentary women with chronic backache. Conclusions. We think that continuing the study with more participants and for a long time will make significant contributions to the literature by producing more positive results. Keywords: Backache, Kinesio banding, Exercise, Flexibility, Sedentary women.
... Lately, plenty of studies were published that strongly suggested the beneficial effect that cognitive-behavioral treatment (CBT) approaches have on managing CLBP. [8][9][10][11] Meticulously enough, mere wording itself has the ability to affect clinical outcomes either negatively or positively in musculoskeletal rehabilitation. 12 Still, no clear CBT pattern exists for LBP patients. ...
Low back pain (LBP) is a common clinical problem imposing a prominent socio-economic burden. The purpose of this systematic review was to investigate the biopsychosocial effects of the Mulligan Concept (MC) of manual therapy (MT) when applied to patient's with LBP. Three researchers independently evaluated the literature quality, and completed a review on five online databases (Medline, Cochrane Library, Science Direct, ProQuest and Google Scholar) for articles published from January 1st 2010 to November 20th 2021, using a combination of free words, Wildcards and Medical Subject Headings (MESH) terms: " Mulligan mobilization " AND " back pain " OR " SNAGs." In total, 62 studies were selected for full-text reading, from which finally 6 studies were included in the present review. The results revealed that the studies where the MC of MT was applied to treat LBP mainly lacked concern regarding the effect that the intervention has on the cognitive and behavioural parameters. The ones that introduced measure outcomes for at least some parts of the cognitive behavioural components, showed that the MC has a positive effect, even though without a long-term follow-up assessment. This review summarized that the evidence of the MC on cognitive behavioural (CB) aspects of patients with LBP is controversial and scarce.
The practice of pain medicine has changed dramatically over the past few years. This practical and accessible evidence-based clinical handbook provides medical and nursing professionals with in-depth and up-to-date information on the various types of chronic pain, the underlying causes, and associated symptoms. Focused primarily on the management of chronic pain, the book covers the major chronic pain conditions in the head and neck, spine, and extremities. Also, it provides invaluable guidance on various pain management techniques, including medication, physical therapy, and psychological interventions. With this knowledge, healthcare professionals will be equipped to provide more effective and compassionate care, improve patients' quality of life, and reduce the risk of chronic pain and opioid dependence. An invaluable resource for pain medicine physicians, anesthesiologiests, primary care physicians, emergency medicine physicians, and nurse anaesthetists as well as those physicians preparing for US Board certification and recertification exams.
Purpose
Accelerometers can be used to objectively measure physical activity. They could be offered to people with chronic low back pain (CLBP) who are encouraged to maintain an active lifestyle. The aim of this study was to examine the use of accelerometers in studies of people with CLBP and to synthesize the main results regarding the measurement of objective physical activity.
Methods
A scoping review was conducted following Arksey and O'Malley's framework. Relevant studies were collected from 4 electronic databases (PubMed, Embase, CINHAL, Web of Science) between January 2000 and July 2023. Two reviewers independently screened all studies and extracted data.
Results
40 publications out of 810 citations were included for analysis. The use of accelerometers in people with CLBP differed across studies; the duration of measurement, physical activity outcomes and models varied, and several limitations of accelerometry were reported. The main results of objective physical activity measures varied and were sometimes contradictory. Thus, they question the validity of measurement methods and provide the opportunity to discuss the objective physical activity of people with CLBP.
Conclusions
Accelerometers have the potential to monitor physical performance in people with CLBP; however, important technical limitations must be overcome.
Background:
Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement, and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes, and how it relates to quantitative changes.
Methods:
A mixed method study in the context of an existing single-case design involving 12 people with disabling non-specific LBP. Interviews were conducted before and after a 12-week physiotherapy-led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualised, quantitative measures of movement, posture, psychological factors, pain, and activity limitation.
Results:
Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterised the embodiment of 'nonconscious protection', while healthcare and societal messages prompted pain-related fear and 'conscious protection'. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention ('conscious non-protection'), but most returned to automatic, normal, and fearless patterns ('non-conscious non-protection'), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures, and less back muscle EMG accompanied positive changes in self-report factors.
Conclusion:
The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non-specific LBP. This involved a re-conceptualisation of movement and posture, from threatening, to therapeutic.
Introduction and objectives
Chronic low back pain is the main cause of disability worldwide, generating high costs for society. To evaluate the prevalence of disability in patients with non-specific chronic low back pain and associated factors, including the impacts of low back pain and psychosocial factors linked to kinesiophobia, catastrophism, anxiety, and depression.
Patients
A cross-sectional study was carried out with 108 adult individuals who had non-specific chronic low back pain. The patients answered previously validated questionnaires, namely the Brief Pain Inventory, the Roland-Morris Disability Questionnaire, the Pain Catastrophizing Scale, the Tampa Kinesiophobia Scale, and the Hospital Anxiety and Depression Scale.
Results
The prevalence of disability observed was 65.7%, with the mean disability score being 15.7 ± 5.3 points in the Roland-Morris Disability Questionnaire. Although pain intensity and other domains of the Brief Pain Inventory, like anxiety, depression, and severe kinesiophobia were significant in the bivariate analyses, they were not associated with disability in the multivariate analysis. Only catastrophic thoughts (prevalence ratio [PR] = 1.19; 95% confidence interval [CI]: 1.07–1.32), and the ‘walking’ domain (PR = 1.08; 95% CI: 1.03–1.14) remained statistically associated with disability.
Conclusion
Pain catastrophization and impact on gait were associated with disability in individuals with non-specific chronic low back pain. Motor control thoughts and behaviors during functional activities were considered to be relevant aspects for the better assessment and treatment of these patients.
Background: Current research practice employs wide-ranging accelerometer wear time criteria to identify a valid day of physical activity (PA) measurement.
Objective: To evaluate the effects of varying amounts of daily accelerometer wear time on PA data.
Methods: A total of 1000 days of accelerometer data from 1000 participants (age=38.7±14.3 years; body mass index=28.2±6.7 kg/m2) were selected from the 2005–2006 National Health and Nutrition Examination Study data set. A reference data set was created using 200 random days with 14 h/day of wear time. Four additional samples of 200 days were randomly selected with a wear time of 10, 11, 12 and 13 h/day1. These data sets were used in day-to-day comparison to create four semisimulation data sets (10, 11, 12, 13 h/day) from the reference data set. Differences in step count and time spent in inactivity (<100 cts/min), light (100–1951 cts/min), moderate (1952–5724 cts/min) and vigorous (≥5725 cts/min) intensity PA were assessed using repeated-measures analysis of variance and absolute percent error (APE).
Results: There were significant differences for moderate intensity PA between the reference data set and semisimulation data sets of 10 and 11 h/day. Differences were observed in 10–13 h/day1 for inactivity and light intensity PA, and 10–12 h/day for steps (all p values <0.05). APE increased with shorter wear time (13 h/day=3.9–14.1%; 12 h/day=9.9–15.2%, 11 h/day=17.1–35.5%; 10 h/day=24.6–40.3%)
Discussion: These data suggest that using accelerometer wear time criteria of 12 h/day or less may underestimate step count and time spent in various PA levels.
Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another.
Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59).
Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points.
Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
Background: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. Purpose: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. Data Sources: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. Study Selection: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. Data Extraction: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). Data Synthesis: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Conclusions: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
Objective
To assess the effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain.
Design
Systematic literature review of randomised controlled trials.
Participants
A total of 1964 patients with disabling low back pain for more than three months.
Main outcome measures
Pain, function, employment, quality of life, and global assessments.
Results
Ten trials reported on a total of 12 randomised comparisons of multidisciplinary treatment and a control condition. There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psychophysical treatments did not improve pain, function, or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments.
Conclusions
The reviewed trials provide evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain. Less intensive interventions did not show improvements in clinically relevant outcomes.
What is already known on this topic
What is already known on this topic
Disabling chronic pain is regarded as the result of interrelating physical, psychological, and social or occupational factors requiring multidisciplinary intervention Two previous systematic reviews of multidisciplinary rehabilitation for chronic pain were open to bias and did not include any of the randomised controlled trials now available
What this study adds
What this study adds
Intensive, daily biopsychosocial rehabilitation with a functional restoration approach improves pain and function in chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes
It is unclear whether the improvements are worth the cost of these intensive treatments
Study Design. A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain. Objective. To test the impact of a novel educational booklet on patients’ beliefs about back pain and functional outcome. Summary of Background Data. The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines. Methods. One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%. Results. Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain. Conclusion. This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients’ beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain.
Design. Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. Objectives. To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. Summary of Background Data. In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new “belief” questionnaires and “sophisticated” performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. Methods. One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. Results. Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. Conclusion. A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy programm—in addition to improving physical function—appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.
Purpose
A novel, minimally invasive posture monitor which can monitor lumbar postures outside the laboratory has demonstrated excellent reliability, as well as concurrent validity compared to a surface marker-based motion analysis system. However, it is unclear if this device reflects underlying vertebral motion.
Methods
Twelve participants performed full range sagittal plane lumbo-pelvic movements during sitting and standing. Their posture was measured simultaneously using both this device (BodyGuard™) and digital videofluoroscopy.
Results
Strong correlations were observed between the two methods (all r
s > 0.88). Similarly, the coefficients of determination were high (all r
2 > 0.78). The maximum mean difference between the measures was located in the mid-range of motion and was approximately 3.4° in sitting and 3.9° in standing.
Conclusion
The BodyGuard™ appears to be a valid method for analysing vertebral motion in the sagittal plane and is a promising tool for long-term monitoring of spinal postures in laboratory and clinical settings in people with low back pain.
ObjectivesTo examine whether patients with chronic low back pain exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT), delivered by physiotherapists; and to examine the association between pre- to post-treatment changes in cognitive factors (cognitive processes) and pre- to post-treatment changes in pain, disability and depression.DesignObservational before–after study.SettingOutpatient physiotherapy department.ParticipantsOne hundred and thirty-seven patients with chronic low back pain.InterventionsIBMT: ‘Work Back to Life’ rehabilitation programme.Main outcome measuresPre- to post-treatment changes in pain, disability and a range of cognitive factors.ResultsPatients demonstrated significant favourable changes for a range of cognitive factors. Furthermore, pre- to post-treatment changes in these cognitive factors explained an additional 22%, 17% and 15% of the variance in changes in pain, disability and depression, respectively, after controlling for other important factors.ConclusionsChanges that emerge in cognitive factors are strongly related to treatment outcome within a physiotherapy treatment context. Specifically, reductions in fear of movement and catastrophising, and increases in functional self-efficacy appear to be particularly important. Modifying these cognitive factors should be seen as a priority when treating patients with chronic low back pain.
The aim of this study was to examine lower lumbar kinematics in cyclists with and without non-specific chronic low back pain (NS-CLBP) during a cross-sectional cycling field study. Although LBP is a common problem among cyclists, studies investigating the causes of LBP during cycling are scarce and are mainly focussed on geometric bike-related variables. Until now no cycling field studies have investigated the relationship between maladaptive lumbar kinematics and LBP during cycling. Eight cyclists with NS-CLBP classified as having a 'Flexion Pattern' (FP) disorder and nine age- and gender-matched asymptomatic cyclists were tested. Subjects performed a 2 h outdoor cycling task on their personal race bike. Lower lumbar kinematics was measured with the BodyGuard™ monitoring system. Pain intensity during and after cycling was measured using a numerical pain rating scale. The NS-CLBP (FP) subjects were significantly more flexed at the lower lumbar spine during cycling compared to healthy controls (p = 0.018), and reported a significant increase in pain over the 2 h of cycling (p < 0.001). One-way repeated measures ANOVA revealed a significant main effect for group (p = 0.035, F = 5.546) which remained just significant when adding saddle angle as a covariate (p = 0.05, F = 4.747). The difference in posture between groups did not change over time. These findings suggest that a subgroup of cyclists with NS-CLBP (FP) demonstrate an underlying maladaptive motor control pattern resulting in greater lower lumbar flexion during cycling which is related to a significant increase in pain.