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Process of Change in Pain-Related Fear: Clinical Insights From a Single-Case of Persistent Back Pain Managed With Cognitive Functional Therapy
Abstract
Study Design
Single case report with repeated measures over 18 months.
Background
Management of persistent low back pain (PLBP) associated with high pain-related fear is complex. This case report aims to provide clinicians with insight into the process of change in a person with PLBP and high bending-related fear, who was managed with an individualized behavioral approach of cognitive functional therapy.
Case Description
A retired manual worker with PLBP believed that his spine was degenerating, that bending would hurt him, and that avoidance was the only form of pain control. At baseline, he presented high levels of pain-related fear on the Tampa Scale of Kinesiophobia (score, 47/68) and a high-risk profile on the Örebro Musculoskeletal Pain Questionnaire (score, 61/100). Unhelpful beliefs and behaviors led to a vicious cycle of fear and disengagement from valued life activities. Guided behavioral experiments were used to challenge his thoughts and protective responses, indicating that his behavior was modifiable and the pain controllable. Using a multidimensional clinical-reasoning framework, cognitive functional therapy management was tailored to target key drivers of PLBP and delivered over 6 sessions in a 3-month period.
Outcomes
Over an 18-month clinical journey, he demonstrated improvements in bending-related fear, pain expectancy, and pain experience, and substantial changes in pain-related fear (Tampa Scale of Kinesiophobia: 33/68; change, −14 points) and risk profile (Örebro Musculoskeletal Pain Questionnaire: 36/100; change, −25 points). Clinical interviews at 6 and 18 months revealed positive changes in mindset, understanding of pain, perceived pain control, and behavioral responses to pain.
Discussion
This case report provides clinicians with an insight to using a multidimensional clinical-reasoning framework to identify and target the key drivers of the disorder, and to using cognitive functional therapy to address unhelpful psychological and behavioral responses to pain in a person with PLBP and high pain-related fear.
Level of Evidence
Therapy, level 5. J Orthop Sports Phys Ther 2017;47(9):637–651. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7371
... In this narrative review, we draw on earlier work that has applied the CSM to understand beliefs and expectations around dyspnoea [19] as well as our own clinical and research experience working with people with COPD [20]. We also provide parallels of how the CSM has been used to understand another noxious symptom: chronic low back pain [21,22]. The aim is to provide a framework to understand nuances that shape an individual's personal construct of dyspnoea and offer practical suggestions to challenge unhelpful beliefs and facilitate cognitive restructuring as a pathway to reduce distress and optimise health behaviours and outcomes. ...
... Communication should be open, empathetic and reflective, and people who are socially connected to the person with COPD, especially those who hold similar unhelpful beliefs, should be included in these therapeutic conversations. With increased trust, people can be prompted to reflect on experiences and influences that led to these misconceptions and the impact these beliefs have on their behaviour [22]. ...
... COPD, especially those who hold similar unhelpful beliefs, should be included in these therapeutic conversations. With increased trust, people can be prompted to reflect on experiences and influences that led to these misconceptions and the impact these beliefs have on their behaviour [22]. ...
Dyspnoea is often the most distressing symptom described by people with a chronic respiratory condition. The traditional biomedical model of neuromechanical uncoupling that explains the physiological basis for dyspnoea is well accepted. However, in people with chronic obstructive pulmonary disease (COPD), measures that are linked with neuromechanical uncoupling are poorly related to the restriction in activity during daily life attributed to dyspnoea. This suggests that activity restriction that results from dyspnoea is influenced by factors other than expiratory airflow limitation and dynamic pulmonary hyperinflation, such as the ways people perceive, interpret and respond to this sensation. This review introduces the common-sense model as a framework to understand the way an individual’s lay beliefs surrounding sensations can lead to these sensations being perceived as a health threat and how this impacts their emotional and behavioural responses. The aim is to provide insight into the nuances that can shape an individual’s personal construct of dyspnoea and offer practical suggestions to challenge unhelpful beliefs and facilitate cognitive re-structuring as a pathway to reduce distress and optimise health behaviours and outcomes.
... pain [35]. The use of a qualitative element via clinical interviews showed that being educated reduces pain and fear of movement, providing insight into patients' perspective on this process [36]. CFT may speculate to lead an individual's perspective to a rapid disruption and guide their behavior toward positive beliefs, enhanced understanding, and control of pain, improved self-efficacy, confidence, and mood. ...
... To support our results, Vibe Fersum et al. (2013) [38] stated that CFT can produce a statistical and clinical superiority on combined manual therapy and exercise for reducing pain intensity (with 3.2 points of improvement compared to 1.5), disability (with 13.7 points of improvement compared to 5.5), and fear avoidance belief in patients with CNSLBP with 3-to 12-month followup maintenance. Caneiro et al. (2017) [36] in their single case report, showed improvement in pain expectancy, pain experience, and kinesiophobia in a male subject after 6 sessions in a 3-month period of CFT. ...
... To support our results, Vibe Fersum et al. (2013) [38] stated that CFT can produce a statistical and clinical superiority on combined manual therapy and exercise for reducing pain intensity (with 3.2 points of improvement compared to 1.5), disability (with 13.7 points of improvement compared to 5.5), and fear avoidance belief in patients with CNSLBP with 3-to 12-month followup maintenance. Caneiro et al. (2017) [36] in their single case report, showed improvement in pain expectancy, pain experience, and kinesiophobia in a male subject after 6 sessions in a 3-month period of CFT. ...
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).
... CFT is a multidimensional, patient-centred intervention that directly explores and manages cognitive, psychological and social factors deemed to be barriers to recovery in CLBP [23][24][25][26][27][28]. This approach is an integrated behavioral approach for individualizing the management of people with disabling LBP [29] once serious (eg, malignancy, infection, inflammatory disorder, and fracture) and specific pathology (eg, nerve root compression with progressive neurological deficit with or without cauda equina symptoms) has been excluded [30]. 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]. ...
... This will include discussing the multidimensional nature of persistent pain as it pertains to the individual-and how beliefs, emotions and behaviours (movement and lifestyle) can reinforce a vicious cycle of pain sensitisation and disability [37]. Exposure with control is a process of behavioral change through experiential learning, in which sympathetic responses and safety behaviors that manifest during painful, feared, or avoided functional tasks are explicitly targeted and controlled [29]. This approach enables individuals to gradually return to their valued functional activities without pain escalation and associated distress [29]. ...
... Exposure with control is a process of behavioral change through experiential learning, in which sympathetic responses and safety behaviors that manifest during painful, feared, or avoided functional tasks are explicitly targeted and controlled [29]. This approach enables individuals to gradually return to their valued functional activities without pain escalation and associated distress [29]. Lifestyle change includes promotion of gradually increasing physical activity based on their preference and presentation, advice on sleep hygiene, stress management strategies and social re-engagement [21,23,38]. ...
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.
... KFB beskrives som et rammeverk for multifaktoriell klinisk resonnering, og har utviklet seg på en integrering av fysioterapeutisk rehabilitering med grunnleggende kognitive og atferdsmessige intervensjoner (11). Rammeverket skal gi en fleksibel individualisert behandling til personer med hemmende ryggsmerter (12). ...
... I tillegg kan multifaktorielle spørreundersøkelser, som f.eks. Örebro screeningskjema, benyttes for å gi ytterligere innsikt i psykososiale faktorer (8,11,12,16). ...
... Etter å ha utelukket alvorlig patologi, fokuserer undersøkelsen på bevegelser og aktiviteter som ble identifisert i samtalen som smertefulle, fryktede og unngåtte (8,11,12,17). Respirasjonsmønster, bevegelsesstrategier (f.eks. sikkerhetsatferd) og kroppslige reaksjoner, er viktige å observere for å identifisere uhensiktsmessige strategier som senere kan adresseres (12). ...
FAGARTIKKEL Kognitiv funksjonsrettet behandling som tilnaerming for fysioterapeuter ved behand-ling av langvarige muskel-og skjelettsmerter
Sammendrag Innledning: Det er en høy forekomst av langvarige muskel-og skjelettsmerter i befolkningen, og mange oppsøker fysioterapeuter for slike plager. Anbefalinger fra oppdaterte retningslinjer og kunnskap om komplek-siteten av smerte belyser et behov for pasientsentrer-te, biopsykososiale tilnaerminger som legger til rette for egenbehandling. Målet med denne fagartikkelen er å kartlegge kognitiv funksjonsrettet behandling som tilnaerming for fysioterapeuter ved behandling av langvarige muskel-og skjelettsmerter.
Hoveddel: Et systematisk søk etter relevante artikler ble gjennomført i EMBASE, CINAHL, SCOPUS, PubMed, Cochrane Central Register of Controlled Trials og AMED i uke 41, 2019. Ti artikler ble inkludert. Kognitiv funk-sjonsrettet behandling bygger på en grundig anamnese og undersøkelse der relevante biopsykososiale faktorer for individets smerte og begrensninger identifiseres. Intervensjonen består av tre hovedkomponenter: «forståelse av smerte», «eksponering med kontroll» og «livsstilsendringer», som tar sikte på å påvirke disse faktorene. Tilnaermingen søker å støtte effektiv egen-behandling gjennom en individuelt tilpasset plan.
Avslutning: Kognitiv funksjonsrettet behandling frem-står som en moderne og kunnskapsbasert tilnaerming som setter egenmestring av langvarige muskel-og skjelettsmerter i fokus. Nøkkelord: Kognitiv funksjonsrettet behandling, langvarige muskel-og skjelettsmerter, biopsykososial tilnaerming.
... CFT is based on clinical reasoning framework designed to identify the modifiable factors that lead to pain and disability in chronic low back pain. [12] It focuses on reconceptualizing the concept of pain by educating the patient about the underlying pain mechanisms, functionally retraining the altered movement patterns and modifying the lifestyle. [8,13] ...
... This approach helps the patient return to their functional activities gradually without pain and associated distress. [12] Specific functional training is designed to discourage pain beliefs, normalize provocative movements and behaviours based on individual presentation. It involves strategies to enhance body awareness and control. ...
... Direct hands-on feedback also can be applied but care should be taken to avoid encouragement of patient dependence. [12,[17][18][19] Lifestyle change: ...
... Cognitive functional therapy was developed as a flexible, integrated behavioral approach for individualizing the management of disabling LBP. 62 Although CFT for disabling LBP is the focus of this article, the principles of CFT can be applied for many people with LBP (Fig. 2). It uses a multidimensional "clinical reasoning framework" to identify key modifiable targets for management on the basis of careful listening to the individual's story and examining the individual's behavioral responses to pain. ...
... Exposure with control is a process of behavioral change through experiential learning, in which sympathetic responses and safety behaviors that manifest during painful, feared, or avoided functional tasks are explicitly targeted and controlled. 62 This approach enables individuals to gradually return to their valued functional activities without pain escalation and associated distress. This process is underpinned by the guided behavioral experiments from the examination, and with consideration of the individual's levels of distress, tissue sensitivity profile (eg, with exaggerated pain responses to minor mechanical stimuli, this process is more gradual), and levels of conditioning. ...
... Individuals are initially seen weekly for 2 or 3 sessions, after which sessions are extended to every 2 or 3 weeks in order to build confidence to self-manage over a 12week period. [62][63][64] During this process, pain flares are seen as an opportunity for reinforcing new ways to respond to pain without safety behaviors and avoidance. An exacerbation plan is provided on discharge in order to positively orientate the individual's emotional and behavioral responses to pain, and booster sessions may be required beyond this time if pain again becomes uncontrollable, distressing and/or disabling. ...
Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual’s disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.
... Kinesiophobia is an excessive, irrational fear of physical activity or movement due to the increased pain sensitivity caused by a painful injury or damage to the body [75]. It may seriously effect recovery, leading to increased muscle weakness, increased pain and a decreased level of daily activities [76]. ...
... Some studies have highlighted the moderate prevalence of kinesiophobia in football players [76,77]. At present, nonpharmacological therapy is the preferred approach for people with chronic pain [78]. ...
Injuries represent a serious concern for football players, with a significant loss in terms of sport participation and long periods of rehabilitation. According to the 2019/20 UEFA Élite Club Injury Report, the average incidence of injuries during training is 2.8 per 1000 h of training, with an average absence from training of 20 days. In addition, injured athletes are 4 to 7 times more likely to relapse than uninjured athletes. High workloads and reduced recovery periods represent two of the most important modifiable risk factors. In this context, prevention and an adequate rehabilitation protocol are vital in managing injuries, reducing their incidence, and improving the return to competition. In recent years, technological development has provided new tools in rehabilitation, and Virtual reality (VR) has shown interesting results in treating neurologic and orthopedic pathologies. Virtual Reality (VR) technology finds application in the sports industry as a tool to examine athletes’ technical movements. The primary objective is to detect the biomechanical risk factors associated with anterior cruciate ligament injury. Additionally, VR can be used to train athletes in field-specific techniques and create safe and controlled therapeutic environments for post-injury recovery. Moreover, VR offers a customizable approach to treatment based on individual player data. It can be employed for both prevention and rehabilitation, tailoring the rehabilitation and training protocols according to the athletes’ specific needs.
... An alternative approach gaining increasing attention in the management of CLBP is cognitive functional therapy (CFT) [16]. CFT consists of multidimensional and personalized exercises that not only emphasize motor control but also consider psychological factors as integral components of the exercises [17]. CFT aims to change the patient's beliefs, and the ability to cope with C Highlights • Low back pain has negative effects on people's psychological factors. ...
... Individuals are trained to reduce the overactivity of the trunk muscles and make behavioral changes related to pain in provocative postures and movements [18]. Clinical trials using CFT have shown promising results [16][17][18]. For example, in a randomized controlled clinical trial (RCT) conducted by Vibe Fersum et al. involving individuals with chronic low back pain, CFT demonstrated superior outcomes in terms of pain reduction and disability compared to manual therapy [19]. ...
Purpose: Chronic non-specific low back pain (CNSLBP) is a common health issue caused by a mix of biological, psychological, and social factors. Cognitive functional therapy (CFT) is a comprehensive way to treat CNSLBP that focuses on changing negative thoughts and unhelpful habits through relaxation techniques. Since the evidence on the efficacy of CFT is still limited, it is essential to conduct clinical trials aimed at the effectiveness of CFT in the treatment of CNSLBP. This study aims to examine the effect of cognitive functional therapy on psychological variables in women with CNSLBP. Methods: Thirty women with CNSLBP were recruited for the clinical trial. They were randomly divided into two experimental and control groups (15 patients in each group). Our experimental group will have 18 individualized CFT sessions, each lasting an hour, over two months. The control group received no intervention. Pain intensity, disability, and kinesiophobia were assessed via the visual analog scale, Oswestry, and Tampa scale, respectively. Two-way repeated measures analysis of variance (ANOVA) was used to compare results between groups. Results: Two-way repeated measures ANOVA results showed that the experimental group compared to the control group in reducing pain (P=0.000, ηp2=0.787), disability (P=0.005, ηp2=0.457) and Kinesiophobia (P=0.000, ηp2=0.561) had a significant difference. Conclusion: CFT reduced pain, disability, and kinesiophobia in patients with CNSLBP. Further evaluation of the efficacy of CFT in high-quality randomized clinical trials among patients with CNSLBP is recommended.
... Cognitive functional therapy and scapular exercise group (multidisciplinary group): the exercises were designed based on previous studies. 14,15 The cognitive functional therapy aimed at altering the perception of pain consisted of patient education regarding the multidimensional nature of ongoing pain, management of flair-ups, functional movement training, physical activity and lifestyle training, visual and kinesthetic motor imagery, functional movement exercises and mirror feedback exercises. The intervention contained the following elements: ...
... Therefore, a combination of factors, such as postural changes, awareness of positive and negative posture situations, improvement in confidence, reduced sense of threat and more relaxed movement patterns, might have reduced the pain and kinesiophobia in patients with neck pain. 14,15 The findings of this study found that upper trapezius, lower trapezius, middle trapezius and serratus anterior muscle activation increased during each degree of arm abduction. The findings indicate that cognitive functional therapy combined scapular exercise demonstrated greater effect compared with the scapular exercise alone group. ...
Objective
The aim of this study was to compare the effectiveness of scapular exercises alone and combined with cognitive functional therapy in treating patients with chronic neck pain and scapular downward rotation impairment.
Design
Single-blind randomized controlled trial.
Setting
Outpatient.
Subjects
A total of 72 patients (20–45 years old) with chronic neck pain were studied.
Intervention
Allocation was undertaken into three groups: scapular exercise (n = 24), scapular exercise with cognitive functional therapy (n = 24) and control (n = 24) groups. Each programme lasted three times a week for six weeks.
Main outcomes
The primary outcome measure was pain intensity measured by the visual analogue scale scores. The secondary outcome measures included kinesiophobia and muscles activity.
Results
Statistically significant differences in pain intensity were found when multidisciplinary physiotherapy group including a cognitive functional approach was compared with the scapular exercise alone group at six weeks (effect size (95% CI) = −2.56 (−3.32 to −1.80); P = 0.019). Regarding kinesiophobia, a significant between-group difference was observed at six-week (effect size (95% CI) = −2.20 (−2.92 to −1.49); P = 0.005), with the superiority of effect in multidisciplinary physiotherapy group. A significant between-group differences was observed in muscle activity. Also, there were significant between-group differences favouring experimental groups versus control.
Conclusion
A group-based multidisciplinary rehabilitation programme including scapular exercise plus cognitive functional therapy was superior to group-based scapular exercise alone for improving pain intensity, kinesiophobia and muscle activation in participants with chronic neck pain.
... Fear of movement remained significantly reduced in the CFT group at 12 months, which is line with previous studies of CFT [21,39,40]. Targeting fear in the treatment of spinal disorders has been proposed to be important, due to its mediating role in the relationship between pain and disability [41]. ...
... Targeting fear in the treatment of spinal disorders has been proposed to be important, due to its mediating role in the relationship between pain and disability [41]. This long-term impact on fear could be explained by the manner in which CFT is providing pain control by targeting unhelpful cognitions, emotions, and protective movement behaviors during patient-nominated painful, feared, or avoided activities (e.g., bending and lifting) [40,42]. This specific process is unique to CFT and distinguishes CFT from other cognitive-based interventions (e.g., CBT) [43]. ...
Background:
Effective, inexpensive, and low-risk interventions are needed for patients with nonspecific persistent low back pain (NS-PLBP) who are unresponsive to primary care interventions. Cognitive functional therapy (CFT) is a multidimensional behavioral self-management approach that has demonstrated promising results in primary care and has not been tested in secondary care.
Objective:
To investigate the effect of CFT and compare it with usual care for patients with NS-PLBP.
Design:
Case-control study.
Setting:
A secondary care spine center.
Subjects:
Thirty-nine patients received a CFT intervention and were matched using propensity scoring to 185 control patients receiving usual care.
Methods:
The primary outcome was Roland Morris Disability Questionnaire (0-100 scale) score. Group-level differences at six- and 12-month follow-up were estimated using mixed-effects linear regression.
Results:
At six-month follow-up, a statistically significant and clinically relevant difference in disability favored the CFT group (-20.7, 95% confidence interval [CI] = -27.2 to -14.2, P < 0.001). Significant differences also occurred for LBP and leg pain, fear, anxiety, and catastrophizing in favor of CFT. At 12-month follow-up, the difference in disability was smaller and no longer statistically significant (-8.1, 95% CI = -17.4 to 1.2, P = 0.086). Differences in leg pain intensity and fear remained significantly in favor of CFT. Treatment satisfaction was significantly higher in the CFT group at six- (93% vs 66%) and 12-month (84% vs 52%) follow-up.
Conclusions:
These findings support that CFT is beneficial for patients with NS-PLBP who are unresponsive to primary care interventions. Subsequent randomized controlled trials could incorporate booster sessions, which may result in larger effects at 12-month follow-up.
... Fear of movement remained significantly reduced in the CFT group at 12 months, which is line with previous studies of CFT [21,39,40]. Targeting fear in the treatment of spinal disorders has been proposed to be important, due to its mediating role in the relationship between pain and disability [41]. ...
... Targeting fear in the treatment of spinal disorders has been proposed to be important, due to its mediating role in the relationship between pain and disability [41]. This long-term impact on fear could be explained by the manner in which CFT is providing pain control by targeting unhelpful cognitions, emotions, and protective movement behaviors during patient-nominated painful, feared, or avoided activities (e.g., bending and lifting) [40,42]. This specific process is unique to CFT and distinguishes CFT from other cognitive-based interventions (e.g., CBT) [43]. ...
Introduction:
Multidisciplinary care is recommended for disabling persistent low back pain (pLBP) nonresponsive to primary care. Cognitive functional therapy (CFT) is a physiotherapy-led individualised intervention targeting psychological, physical, and lifestyle barriers to recovery, to self-manage pLBP.
Objectives:
This pilot study investigated clinical outcomes and pain thresholds after a 12-week CFT pathway in patients with severe pLBP referred to a University Pain Center. Exploratory analyses compared changes in clinical outcomes, opioid consumption, and costs after CFT with changes after a multidisciplinary pain management (MPM) pathway.
Methods:
In total, 47 consecutively referred pLBP patients consented to the CFT pathway. At baseline, 3 and 6 months, clinical outcomes and PPTs were assessed. Control patients (n = 99) who had completed an MPM pathway in the last 3 years were matched from the clinical pain registry used in the Pain Center in a 3:1 ratio based on propensity scores derived from relevant baseline variables of the CFT cases.
Results:
Most clinical outcomes and low back pressure pain threshold were improved at 3 and 6 months after the CFT pathway. Compared with MPM, CFT patients had significantly larger reductions in disability and improved quality of life after the interventions at a lower cost (-3688€ [confidence interval: -3063 to -4314€]). Reduction in pain intensity and proportion of patients withdrawing from opioids (18.2% vs 27.8%) were similar between CFT and MPM groups.
Conclusion:
Improvements in clinical and experimental pain were found after the CFT pathway. Fully powered randomized controlled trials comparing CFT with an MPM program in patients with disabling pLBP are warranted to control for the current limitations.
... Maladaptive movement patterns (e.g. cautious tensed movements) [12] and maladaptive respiration patterns (e.g. shallow thoracic breathing, withholding breath during movements) are commonly observed [13,14]. ...
... shallow thoracic breathing, withholding breath during movements) are commonly observed [13,14]. These maladaptive patterns can also potentially be targeted during treatment of NSCLBP, both through specific exercises and cognitive behavioural approaches [12]. Currently, there is no agreement, amongst health professionals, on how movement quality should be standardised in patients with nonspecific LBP [15]. ...
Introduction
Nonspecific chronic low back pain is a multifactorial biopsychosocial health problem where accurate assessments of pain, function and movement are vital. There are few reliable and valid assessment tools evaluating movement quality, hence the aim was to investigate nonspecific chronic low back pain patients’ movement patterns with the Standardised Mensendieck Test.
Methodology
Twenty patients (mean age=41, SD=9.02) with nonspecific chronic low back pain were examined with the Standardised Mensendieck Test whilst being videotaped and compared with 20 healthy controls. A physiotherapist, blinded to participant’s group belonging, scored Standardised Mensendieck Test videos according to the standardised manual. Associations between movement quality, fear of movement and re(injury) i.e. kinesiophobia and pain intensity were also investigated.
Results
Patients scored significantly poorer than the controls in all 5 Standardised Mensendieck Test domains ( p <0.001). The biggest difference was observed with regard to movement pattern domain. In women we also found a difference in the respiration pattern domain.
Conclusions
The Standardised Mensendieck Test was able to detect significant differences in quality of movement between patients and healthy controls. These results indicate that the Standardised Mensendieck Test may be a valuable examination tool in assessment and treatment of nonspecific chronic low back pain patients. Further, longitudinal studies should investigate whether poor movement and respiration patterns are important factors in nonspecific chronic low back pain, e.g. as predictors and/or mediators of therapeutic effects.
... [ DOI: 10.61186/jrums.23.6.552 ] [ Downloaded from journal.rums.ac.ir on 2024-[10][11][12][13][14][15][16][17][18][19][20][21] ...
Background and Objectives: Chronic non-specific low back pain (CNSLBP) is a common health issue caused by a mix of biological,psychological, and social factors. Cognitive functional therapy (CFT) is a multidimensional approach that considers the interaction between motor control and psychological factors as an important part of the rehabilitation protocol. The aim of the present study was determining the effect of cognitive functional therapy on gait parameters and psychological variables in women with CNSLBP.
Materials and Methods: This clinical trial was carried out at the University of Bu-Ali Sina in 2022. Forty women with CNSLBP were selected by convenience sampling method and randomly assigned into experimental and control groups (20 people in each group). The experimental group performed CFT exercises for 8 weeks, while the control group did not receive any intervention. The primary outcome included pain, disability, and kensiophobia (fear of movement) and the secondary outcome was vertical ground reaction force (VGRF) parameters. Data was analyzed using multivariate analysis of covariance (MANCOVA).
Results: The covariance results showed that the CFT intervention had a significant effect in the experimental group compared to the control group in reducing pain, disability, and kinesiophobia (p<0.001). Also, CFT intervention had a significant effect on improving gait kinetics (p<0.001).
Conclusion: Cognitive functional therapy reduced pain, disability, and kinesiophobia. In addition, some modifications in gait kinetics were observed in people with non-specific chronic back pain. Cognitive functional therapy appears to be an appropriate and applicable treatment in clinical setting.
... For example, studies have demonstrated that placebo manipulations can improve fatigue and motor performance in healthy participants (Carlino et al., 2014;Piedimonte et al., 2015) as well as those with Parkinsons (Benedetti, 2008). Additionally, cognitive behavioral therapy and cognitive functional therapy have been shown to reduce pain-related fear-avoidance beliefs (Caneiro et al., 2017;Linden et al., 2014;Lohnberg, 2007) and disability (Schemer et al., 2019;Urits et al., 2019), and counterconditioning and extinction techniques have been shown to reduce pain-related nocebo effects and fear Meijer et al., 2023;Meulders et al., 2015;Thomaidou et al., 2020), itch-related nocebo effects (Bartels et al., 2017), as well as anxiety-related avoidance behavior (Hulsman et al., 2024). Thus, a reasonable next step may be to expand existing treatments that already target expectancies and avoidance behaviors. ...
... In these cases, the journey towards living is the experiment itself. 25,72 Exposure can be very challenging for the patient as well as the clinician who needs to support the patient along the journey. To guide their patient to engage in painful, feared, and/or avoided movements and activities, clinicians need to be confident they have adequately screened for specific and underlying pathology and that they will not "harm" the patient in this process. ...
Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening, and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain, as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing cognitive functional therapy to promote safety learning. A process is described in which experiential learning combined with “sense making” disrupts a person’s unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.
... In this study, CFT+ will be delivered by one of two physical therapists who have extensive training and clinical supervision in CFT, and one of two pain psychologists who have been trained in the CFT model. 9,17 The role of the psychologist will be to address psychosocial factors identified within the multidimensional clinical reasoning framework as key drivers of ongoing pain or as barriers to engagement in CFT (eg, elevated anxiety or depression, problems in the social environment, motivational barriers) during the joint sessions 1 and 2 (both the physical therapist and the psychologist present). ...
Objective
Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe cLBP. Such programs are expensive, not easily accessible, and have limited effect and therefore new cost-effective strategies are warranted. Cognitive Functional Therapy (CFT) has shown promising results, but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial (RCT) is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed), is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care).
Methods
This pragmatic, two-arm, parallel-group RCT will randomly allocate patients (n = 176) aged 18 to 75 referred to an interdisciplinary pain center due to severe cLBP to one of two groups (1:1 ratio). Patients randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed) while patients randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual patient's situation, needs and resources. The primary outcome is the proportion of patients with an 8-point improvement in the Oswestry Disability Index (ODI) score at 12 months. Exploratory outcomes is change in ODI scores over time, and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D.
Impact
The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for patients with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.
... Although pain neuroscience education is a possibly effective strategy, it is a way of addressing cognitive aspects that differs from those proposed by CFT intervention. The authors claim to follow the protocols for cognitive restructuring by Caneiro et al. 7 and O'Sullivan et al., 3 who propose a reflective process within the biopsychosocial context, using analogies, metaphors, and associations between painful condition and relevant life events. Thus, the patient can better understand his condition and reframe his previous beliefs about pain. ...
... Clinicians must use pain flares as an opportunity for reinforcing the new representation and new ways to respond to pain without emotional distress, protective behaviours and avoidance of movement, physical, work or social engagement. 66,85 The critical role that beliefs can have on the outcome of musculoskeletal pain is illustrated in Table 4 (Jamie's story ---a journey to recovery) and here (an interview with Jamie). These beliefs include those of the clinician and the patient. ...
Background
Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by it. Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability. Clinical guidelines recommend addressing unhelpful beliefs as the first line of treatment in all patients presenting with musculoskeletal pain. However, many clinicians hold unhelpful beliefs themselves; while others feel ill-equipped to explore and target the beliefs driving unhelpful responses to pain. As a result, clinicians may reinforce unhelpful beliefs, behaviours and resultant disability among the patients they treat.
Methods
To assist clinicians, in Part 1 of this paper we discuss what beliefs are; how they are formed; the impact they can have on a person's behaviour, emotional responses and outcomes of musculoskeletal pain. In Part 2, we discuss how we can address them in clinical practice. A clinical case is used to illustrate the critical role that beliefs can have on a person's journey from pain and disability to recovery.
Conclusions
We encourage clinicians to exercise self-reflection to explore their own beliefs and better understand their biases, which may influence their management of patients with musculoskeletal pain. We suggest actions that may benefit their practice, and we propose key principles to guide a process of behavioural change.
... The McKenzie approach also includes a psychosocial element (Takasaki et al., 2014). This element focuses on changing patients' pain behaviours and cognitions through patient education and is designed to empower patients to attain active self-management strategies and problem-solving techniques to self-control symptoms (May, 2007;May & Donelson, 2008;McKenzie & May, 2003) There are also formal cognitive behavioural approaches (CBA) described in the literature that are utilized by physiotherapists during rehabilitation to improve outcomes (Caneiro, Smith, Rabey, Moseley, & O'Sullivan, 2017;Richmond et al., 2015). In a recent meta-analysis, Richmond et al. provided evidence that CBA interventions are clinically effective (Richmond et al., 2015). ...
Objectives
Graded activity and graded exposure are recommended cognitive behavioural approaches to improve function and pain outcomes for patients receiving physiotherapy for chronic nonspecific low back pain. Directional preference identified following the McKenzie method is also associated with favourable patient outcomes. Study objectives were to examine associations between graded activity and/or graded exposure, and directional preference or no directional preference combined with or without graded activity/graded exposure subgroups, and function and pain outcomes among patients with chronic nonspecific low back pain managed by clinicians credentialed in the McKenzie approach.
Method
Cohort study: Subjects (n = 801) with chronic nonspecific low back pain completed intake surveys, that is, the Lumbar Computer Adaptive Test measuring function and the Numeric Pain Rating Scale measuring pain, and questions addressing their demographic, lifestyle, and health status. Directional preference was determined at intake. Treatment with graded activity/graded exposure during the episode of care was recorded. Function and pain measures were repeated at discharge. Two models were developed controlling for potential confounding effects. The first model examined associations between patients receiving versus not receiving graded activity/graded exposure. The second model examined interaction effects between four combinations of directional preference and graded activity/graded exposure. Outcome measures were changes in function and pain during rehabilitation.
Results
Regarding the first objective, there were no clinically relevant differences between treatment versus no treatment with graded activity/graded exposure, and functional outcomes. Regarding the second objective, patients in the no‐directional preference group were more likely to see benefits from the addition of graded activity/graded exposure to their treatment groups than those with a directional preference.
Conclusion
Clinicians using McKenzie methods might attain improved patient functional outcomes when augmenting treatment with graded activity and/or graded exposure among patients who do not demonstrate directional preference.
... Clinical trials have shown that standard tasks such as sitting posture and lumbar ROM during forward bending did not change after CFT (O' Sullivan et al., 2015;Vibe Fersum et al., 2013). In contrast, several case studies that evaluated patient-specific activities showed that an improvement in pain and disability was associated with a less protective movement behaviour after CFT (Caneiro, Ng, Burnett, Campbell, & O'Sullivan, 2013;Caneiro, Smith, Smith, Rabey, Moseley, & O'Sullivan, 2017;Meziat Filho, 2016). Therefore, it might be more appropriate to evaluate the specific movements that were targeted during treatment instead of using standardized tasks. ...
Background
Most studies fail to show an association between higher levels of pain‐related fear and protective movement behavior in patients with chronic low back pain (CLBP). This may be explained by the fact that only general measures of pain‐related fear have been used to examine the association with movement patterns. This study explored whether task‐specific, instead of general measures of pain‐related fear can predict movement behavior.
Methods
Fifty‐five patients with CLBP and 54 healthy persons performed a lifting task while kinematic measurements were obtained to assess lumbar range of motion (ROM). Scores on the Photograph Daily Activities Series‐Short Electronic Version (PHODA‐SeV), Tampa Scale for Kinesiophobia and its Activity Avoidance and Somatic Focus subscales were used as general measures of pain‐related fear. The score on a picture of the PHODA‐SeV, showing a person lifting a heavy object with a bent back, was used as task‐specific measure of pain‐related fear.
Results
Lumbar ROM was predicted by task‐specific, but not by general measures of pain‐related fear. Only the scores on one other picture of the PHODA‐SeV, similar to the task‐specific picture regarding threat value and movement characteristics, predicted the lumbar ROM. Compared to healthy persons, patients with CLBP used significantly less ROM, except the subgroup with a low score on the task‐specific measure of pain‐related fear, who used a similar ROM.
Conclusions
Our results suggest to use task‐specific measures of pain‐related fear when assessing the relationship with movement. It would be of interest to investigate whether reducing task‐specific fear changes protective movement behavior.
This article is protected by copyright. All rights reserved.
... In the context of our results, we speculate that once pain is felt during bending or lifting, it provides a salient learning experience [33,50,57] in which a 'protect the back' schema may be activated. In line with this thinking, experimental studies have reported pain reduction during forward bending following interventions that aim to de-threaten bending via pain education [58], the use of visual observation of the spine during the movement [59], or providing cognitive and functional control during behavioural exposure [60]. Together, our results provide support for the argument that self-reported pain-related fear may be more cognitively-driven, in which an unhelpful schema may influence avoidance behaviour, and a physiological threatresponse may only occur when the person is exposed to the task itself [15,61]. ...
Background and aims:
Pain and protective behaviour are dependent on implicit evaluations of danger to the body. However, current assessment of perceived danger relies on self-report, on information of which the person is aware and willing to disclose. To overcome this limitation, attempts have been made to investigate implicit evaluation of movement-related threatening images in people with persistent low back pain (PLBP) and pain-related fear. Lack of specificity of the sample and stimuli limited those explorations. This study investigated implicit evaluations and physiological responses to images of tasks commonly reported as threatening by people with PLBP: bending and lifting. We hypothesized that people who differ in self-reported fear of bending with a flexed lumbar spine (fear of bending) would also differ in implicit evaluations and physiological responses.
Methods:
This study used a convenience sample of 44 people (54% female) with PLBP, who differed in self-reported fear of bending. Participants completed a picture-viewing paradigm with pleasant, neutral and unpleasant images, and images of people bending and lifting with a flexed lumbar spine ('round-back') to assess physiological responses (eye-blink startle modulation, skin conductance). They also completed an implicit association test (IAT) and an affective priming task (APT). Both assessed implicit associations between (i) images of people bending/lifting with a flexed lumbar spine posture ('round-back' posture) or bending/lifting with a straight lumbar spine posture ('straight-back' posture), and (ii) perceived threat (safe vs. dangerous).
Results:
An implicit association between 'danger' and 'round-back' bending/lifting was evident in all participants (IAT (0.5, CI [0.3; 0.6]; p<0.001) and APT (24.2, CI [4.2; 44.3]; p=0.019)), and unrelated to self-reported fear of bending (IAT (r=-0.24, 95% CI [-0.5, 0.04], p=0.117) and APT (r=-0.00, 95% CI [-0.3, 0.3], p=0.985)). Levels of self-reported fear of bending were not associated with eye-blink startle (F(3, 114)=0.7, p=0.548) or skin conductance responses (F(3, 126)=0.4, p=0.780) to pictures of bending/lifting.
Conclusions:
Contrary to our expectation, self-reported fear of bending was not related to physiological startle response or implicit measures. People with PLBP as a group (irrespective of fear levels) showed an implicit association between images of a round-back bending/lifting posture and danger, but did not display elevated physiological responses to these images. These results provide insight to the understanding of the relationship between pain and fear of movement.
Implications:
The potential clinical implications of our findings are twofold. First, these results indicate that self-report measures do not always reflect implicit associations between particular movements and threat. Implicit association tasks may help overcome this limitation. Second, a lack of the predicted physiological and behavioural responses may reflect that the visualization of a threatening task by people in pain does not elicit the same physiological defensive responses measured in people with fear of specific objects. It may be necessary to expose the person to the actual movement to elicit threat-responses. Together, these results are consistent with current views of the role of 'fear' in the fear-avoidance model, in which a fear response may only be elicited when the threat is unavoidable.
Background
Kinesiophobia is a significant factor affecting the prognosis of patients with total hip arthroplasty (THA). At present, the primary intervention for kinesiophobia is a 1-way intervention process of healthcare professionals on patients. The video teach-back method uses bidirectional information feedback to ensure high-quality health education. However, little is known about the effect of the video teach-back method on kinesiophobia in patients after unilateral THA.
Purpose
To explore the effect of the video teach-back method on the degree of kinesiophobia, hip function, the first ambulation time, hospitalization days, and hospitalization costs in patients after THA.
Methods
This quasi-experimental study was conducted in the Department of Joint Surgery of a grade III hospital in Changchun City, Jilin Province, targeting patients with kinesiophobia following unilateral THA. A nonconcurrent control design was employed, with participants divided into an intervention group (n = 46) and a control group (n = 45). The control group received conventional care, while the intervention group received video teach-back intervention in addition to traditional care. Within 24 hours post-surgery, patients with a kinesiophobia score of more than 37 completed a general information questionnaire. Primary outcomes, including kinesiophobia and hip function, were assessed on discharge day, 1 and 3 months after surgery, and counted on the day of discharge. Repeated-measures analysis of variance was used to analyze the differences in observation indexes at different time points. Secondary outcomes included the first postoperative ambulation time, hospitalization days, and hospitalization costs.
Results
In comparison between the intervention group and the control group, the kinesiophobia scores and hip function scores of the patients on the discharge date, the first and third months after surgery, had a time effect (P < .001), a group effect (P < .001). The intervention group’s reduction in kinesiophobia had a significant effect size (Cohen’s d = 0.82) and hip function improvement also demonstrated a significant effect size (Cohen’s d = 0.77). The first postoperative ambulation time in the intervention group was significantly earlier than that in the control group (P < .05, Cohen’s d = 0.55), with both hospitalization days and costs lower than in the control group; the differences were statistically significant (P < .05).
Conclusion
The intervention group showed improvements in kinesiophobia, hip function, first postoperative ambulation time, hospitalization days, and hospitalization costs. These findings suggest that the video teach-back method, as an effective intervention, can be widely applied in clinical practice.
Trial Registration Number
The trial was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2400079966).
Purpose of the article:
Walking disorders are a significant issue for patients with low back pain. The aim of clinical trials is to compare the effects of cognitive functional therapy (CFT) and neurofeedback training (NFBT) on gait kinetics in chronic non-specific low back pain (CNSLBP) patients.
Materials and methods:
Sixty females with chronic non-specific low back pain were recruitment for clinical trials. They were randomly divided into experimental and one control groups (Each group 20 patients). The experimental group received the relevant interventions for eight weeks. The primary outcome was pain, kinesiophobia and disability. The secondary outcome was vertical ground reaction force (VGRF) parameters. Two-Way Repeated Measures ANOVA statistical method was used for data analysis.
Results:
Within-group comparisons showed that neurofeedback training and cognitive functional therapy groups experienced significant improvement in pain intensity, disability and kinesiophobia after eight-week (p < 0.05). However, the cognitive functional therapy group improved the vertical ground reaction force parameters better than the neurofeedback training group (p < 0.05).
Conclusions:
cognitive functional therapy intervention had a greater effect on the vertical ground reaction force parameters. The reason for the greater effect of cognitive functional therapy intervention on vertical ground reaction force parameters can be partially explained due to the multimodal therapy used through cognitive exercises and motor control.
Objective
To assess the effectiveness of cognitive functional therapy (CFT) in reducing disability and pain compared to other interventions in chronic spinal pain patients.
Methods
Five databases were queried to October 2023 for retrieving randomized controlled trials (RCTs), including patients with chronic spinal pain and administering CFT. Primary outcomes were disability and pain. Secondary outcomes included psychological factors, quality-of-life, patient satisfaction and adverse events. Two independent reviewers performed study selection, data extraction, risk of bias assessment (Cochrane RoB 2.0), and evidence certainty (GRADE approach). Random-effect models were used for meta-analyses. Clinical relevance was assessed with the Smallest Worthwhile Effect.
Results
Eight RCTs (N = 1228) for chronic low back pain (CLBP), one (N = 72) for chronic neck pain (CNP) were included. Compared to other conservative interventions, CFT may reduce disability (MD: -9.41; 95%CI: -12.56, -6.27) and pain (MD: -1.59; 95%CI: -2.33, -0.85 for CLBP) at short-term follow-up with probable to possible clinical relevance in CLBP and with low and very low evidence certainty, respectively. Similar results, with larger effect sizes, were observed for CFT compared to any unstructured or unsupervised minimal care treatments. Efficacy persisted in longer-term follow-ups, except for comparison with other conservative interventions. The CNP study showed positive results for CFT. Evidence certainty was low to very low. Sparse evidence was found for secondary outcomes.
Conclusion
CFT may offer clinically relevant benefits for CLBP, although the evidence remains mainly of low to very low certainty. Well-conducted studies, particularly in CNP and other spinal pain conditions are needed to strengthen these findings.
Registration
PROSPERO CRD42023482667
Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients’ perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of “The Journey to Self-Management.” Within this overarching narrative, four distinct narratives were identified, beginning with “Left High and Dry,” capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included “Plain, Smooth Sailing,” describing a journey of relative ease and lack of obstacles; “Learning the Ropes and Gaining Sea Legs,” capturing an iterative process of learning and negotiating setbacks; and “Sailing Through Headwinds,” describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.
Low back pain is the leading cause of disability worldwide, and sacroiliac dysfunction is estimated to occur in 15%–30% of those with nonspecific low back pain. Nurses are in the unique position to support and provide education to patients who may be experiencing sacroiliac dysfunction or possibly apply this knowledge to themselves, as low back pain is a significant problem experienced by nurses. A patient's clinical presentation, including pain patterns and characteristics, functional limitations, common etiologies and musculoskeletal system involvement, current diagnostic tools, and realm of treatments, are discussed along with their respective efficacy. Distinction is made between specific diagnosis and treatment of joint involvement and that of sacroiliac regional pain, as well as other factors that play a role in diagnosis and treatment for the reader's consideration.
Background
Physiotherapists trained to deliver biopsychosocial interventions for complex musculoskeletal pain problems often report difficulties in confidence and competency at the end of training. Cognitive Functional Therapy (CFT) is an individualized biopsychosocial intervention and understanding the facilitators and barriers to training in CFT will help inform future training programs. This study aimed to explore physiotherapists’ and trainers’ perceptions of the process of developing competency in CFT.
Methods
A cross-sectional qualitative design using interviews of 18 physiotherapists and two trainers investigated training in CFT for persistent LBP via reflexive thematic analysis.
Results
Physiotherapists reported undergoing a complex behavior change process during training. Four themes emerged: 1) Pre-training factors; 2) Behavior change process; 3) Physiotherapy culture and context; and 4) Confident competence and beyond. Key components included graduated practice exposure linked to experiential learning with feedback and clear competency guidelines. Pre-training and contextual factors were facilitators or barriers depending on the individual. Physiotherapists supported ongoing learning, even after competency was achieved.
Conclusions
This study provides insight into the processes of change during progress toward competency in CFT. It highlights facilitators and barriers to competency including physiotherapy culture and the clinical environment. The study also describes important educational components, including experiential learning and clinical integration, which may be used to inform future post-graduate training.
Aims and objective:
To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.
Background:
Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.
Design:
A meta-analysis of randomised controlled trials.
Methods:
This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.
Results:
Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).
Conclusions:
Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.
Relevance to clinical practice:
This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.
Background: Chronic non-specific low back pain (CNSLBP) is a public health issue associated with a complex interaction of biopsychosocial factors. Cognitive Functional Therapy is a multidimensional approach for CNSLBP which targets negative cognitions and maladaptive functional behaviors (via body relaxation, control and extinction of protective and safety behaviors). Since the evidence about the efficacy of CFT is still limited, it is important to perform clinical trials with the aim of comparing CFT with other interventions commonly used in clinical practice of physiotherapy. The current study will investigate the efficacy of Cognitive Functional Therapy (CFT) compared to combined Core Training exercise and manual therapy (CORE-MT) on pain and disability in patients with CNSLBP.
Methods: Two-group, randomized controlled trial with blinded assessors. We will recruit 148 patients with CNSLBP in a private clinic in the city of Campinas, Brazil. The experimental group will receive five one-hour individualized sessions of CFT within a period of two months. The control group will receive five one-hour individualized sessions of CORE-MT within a period of two months. Patients will be assessed pre-intervention, post-intervention and after six and twelve months. The primary outcomes will be pain intensity and disability two months after first intervention session; secondary outcomes will be pain intensity and disability at six and twelve months, as well as global perceived effect and patient satisfaction at two, six and twelve months after the first intervention session. Non-specific predictors, moderators and mediators of outcomes will also be analyzed.
Discussion: The result of a high-quality randomized controlled clinical trial involving CFT will assist physiotherapists in the clinical decision-making process. The present study will have a sample size capable of detecting relevant clinical effects of treatment with a low risk of bias.
Trial registration: The protocol has been written according to the SPIRIT statement to enhance transparency of content and completeness, has been approved by the Augusto Motta University Center Ethics Committee (research protocol number 2.219.742) and the findings of the trial will be reported following the CONSORT statement and the TIDieR checklist.
Trial registration number: NCT03273114
[(Persian)].
AbSTrACT Aims and background: Neck pain is one of the most common problems in human societies. There are many factors involved in the etiology of neck pain, and cognitive problems related to pain are among the most important factors involved for non-specific neck pain. The aim of this study was to investigate the effect of six weeks of functional cognitive training on the pain intensity, disability and Kinesiophobia in people with non-specific chronic neck pain. Material and Methods: The present study was a clinical trial study with one intervention group and one control group. In this clinical trial study, 24 patients with chronic neck pain were randomly divided into two groups of Cognitive Functional Exercise (n=12) and Control (n=12). The variables of pain intensity, disability, and Kinesiophobia were evaluated before and immediately after six weeks of cognitive exercises by the Visual Analog Scale, neck disability questionnaire, and Tampa Scale of Kinesiophobia, respectively. Data were analyzed using Repeated Measures ANOVA and paired t-test. results: Comparing the two groups after treatment, there was a significant difference in pain intensity (P =0.001), disability index (P = 0.001), and Tampa Scale of Kinesiophobia (P = 0.001) was observed, so that in the intervention group in all factors a significant decrease was observed. Also, the results of the T-pair test showed that there is a significant difference in the group of intervention before and after the test in all variables (P = 0.001). But there was no significant difference for the control group. Conclusion: The findings showed that the intervention of functional cognitive exercises improves pain, disability, and Kinesiophobia in people with chronic neck pain, so it is suggested that functional cognitive exercises can be used as a complementary method in improving individuals with non-specific chronic neck pain.
Background
The lifetime prevalence of low back pain (LBP) is high and recurrence is common. Graded motor imagery is a treatment method used in patients with chronic pain that has 3 stages: left/right discrimination or laterality recognition, explicit motor imagery, and mirror therapy.
Case Presentation
A 33-year-old man self-referred to physical therapy for chronic LBP. He demonstrated misconstrued beliefs regarding his LBP, impaired laterality recognition, and fear-avoidance behaviors.
Outcome and Follow-Up
This “monkey see, monkey do” approach, in conjunction with other interventions, resulted in a 10% improvement of modified Oswestry Disability Index score, greater than 90% laterality accuracy, and a reduction in pain levels.
Discussion
Graded motor imagery can facilitate sensory cortex reorganization. A unique approach to improving laterality recognition was demonstrated in this case: the patient could not improve his laterality scores to acceptable levels until he watched his wife successfully complete the task. JOSPT Cases 2021;1(1):61–67. doi:10.2519/josptcases.2021.9875
In 2017, the Secretary of Health and Human Services and Office of the Surgeon General declared the opioid crisis of our nation to be a public health emergency. In response to the Office of the Assistant Secretary of Health and Office of the Surgeon General’s ‘Call to Action’, the Therapist category of the US Public Health Service commissioned a nine-member task force consisting of pain science subject matter experts to study the Therapists’ role in effectively reducing chronic pain and opioid abuse. This article addresses the opioid epidemic, how patients with chronic pain have been managed inappropriately, and five key, evidence-based recommendations from this task force.
Purpose:
To understand the process of change at an individual level, this study used a single-case experimental design to evaluate how change in potential mediators related to change in disability over time, during an exposure-based behavioural intervention in four people with chronic low back pain and high pain-related fear. A second aim was to evaluate whether the change (sequential or simultaneous) in mediators and disability occurred at the same timepoint for all individuals.
Results:
For all participants, visual and statistical analyses indicated that changes in disability and proposed mediators were clearly related to the commencement of Cognitive Functional Therapy. This was supported by standard outcome assessments at pre-post timepoints. Cross-lag correlation analysis determined that, for all participants, most of the proposed mediators (pain intensity, pain controllability, and fear) were most strongly associated with disability at lag zero, suggesting that mediators changed concomitantly and not before disability. Importantly, these changes occurred at different rates and patterns for different individuals, highlighting the individual temporal variability of change.
Conclusion:
This study demonstrated the interplay of factors associated with treatment response, highlighting 'how change unfolded' uniquely for each individual. The findings that factors underpinning treatment response and the outcome changed simultaneously, challenge the traditional understanding of therapeutic change.
The biomedical model is still used to diagnose chronic lower back pain by the majority of Japanese physicians. A new approach to chronic lower back pain called cognitive functional therapy (CFT) was developed by Peter O'Sullivan based on the biopsychosocial model. This is a physiotherapist-led approach and differs from other foundational cognitive interventions. There is much evidence of the use of CFT. For example, CFT has shown promising results in the reduction of fear, pain and disability in the long term. For chronic lower back pain, the biopsychosocial model is essential to manage patient conditions. Therefore, we should understand the biopsychosocial model and put it to practice. CFT is helpful to understand the model and can improve patient outcomes.
A literature review indicates that behavioral assessment methods assess 3 categories of behavior: overt motor, cognitive-verbal, and physiologic. Evidence for the efficacy of operant conditioning and self-management techniques is presented. Data from both multimodal pain-treatment programs and controlled studies are reviewed. Advances in behavioral assessment research allow for a more precise and objective analysis of the behavior of chronic-pain patients. Controlled treatment–outcome studies suggest that behavioral methods may help modify pain behavior and pain report in chronic-pain patients. (93 ref)
The Common-Sense Model of Self-Regulation (the “Common-Sense Model”, CSM) is a widely used theoretical framework that explicates the processes by which patients become aware of a health threat, navigate affective responses to the threat, formulate perceptions of the threat and potential treatment actions, create action plans for addressing the threat, and integrate continuous feedback on action plan efficacy and threat-progression. A description of key aspects of the CSM’s history—over 50 years of research and theoretical development—makes clear the model’s dynamic underpinnings, characteristics, and assumptions. The current article provides this historical narrative and uses that narrative to highlight dynamic aspects of the model that are often not evaluated or utilized in contemporary CSM-based research. We provide suggestions for research advances that can more fully utilize these dynamic aspects of the CSM and have the potential to further advance the CSM’s contribution to medical practice and patients’ self-management of illness.
Moderator analyses are reported for post-treatment outcomes in a large, randomized, controlled effectiveness trial for chronic pain for hip and knee osteoarthritis (OA) (N=256). Pain Coping Skills Training, a form of cognitive behavioral therapy, was compared to usual care. Treatment was delivered by nurse practitioners in patients' community doctors' offices. Consistent with meta-analyses of pain CBT efficacy, treatment effects in this trial were significant for several primary and secondary outcomes, but tended to be small. This study was designed to examine differential response to treatment for patient subgroups to guide clinical decision making for treatment. Based on existing literature, demographic (age, sex, race/ethnicity, education) and clinical variables (disease severity, BMI, patient treatment expectations, depression, and patient pain coping style) were specified a priori as potential moderators. Trial outcome variables (N=15) included pain, fatigue, self-efficacy, quality of life, catastrophizing, and use of pain medication. Results yielded five significant moderators for outcomes at post-treatment: pain coping style, patient expectation for treatment response, radiographically-assessed disease severity, age, and education. Thus, sex, race/ethnicity, BMI, and depression at baseline were not associated with level of treatment response. In contrast, patients with interpersonal problems associated with pain coping did not benefit much from the treatment. Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited. Patients with moderate to high OA disease severity showed stronger treatment effects. Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.
BACKGROUND:
Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.
DISCUSSION:
LBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients.
CONCLUSIONS:
Investigations of trajectories underpin the notion that differentiation between acute and chronic LBP is overly simplistic, and we believe it is time to shift from this paradigm to one that focuses on trajectories over time. We suggest that trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients, and might have a potential for supporting clinical decision making, but their usefulness is still underexplored.
Chronic pain is incredibly complex, and so are decisions as to its treatment. During physical therapy care, pain neuroscience education (PNE) aims to help patients understand more about their pain from a biological and physiological perspective. Accompanying the growing evidence for the ability of PNE to reduce pain and disability in patients with chronic pain is an increased interest in PNE from scientists, educators, clinicians, and conference organizers. However, the rise in popularity of PNE has highlighted a historical paradox of increased knowledge not necessarily corresponding with improved care. This Viewpoint discusses the growth and popularity of PNE as well as critical future considerations such as clinical application, clinical research, appropriate outcome measures, and the blending of pain education with exercise and manual therapy.
J Orthop Sports Phys Ther 2016;46(3):131–134. doi:10.2519/jospt.2016.0602
Importance
Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP).Objective
To investigate the effectiveness of interventions for prevention of LBP.Data Sources
MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014.Study Selection
Randomized clinical trials of prevention strategies for nonspecific LBP.Data Extraction and Synthesis
Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence.Main Outcomes and Measures
The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models.Results
The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30 850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low–quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low–quality evidence of no effect on LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low–quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]).Conclusion and Relevance
The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.
Low Back Pain (LBP) remains a common and costly problem. Psychological obstacles to recovery have been identified, but psychological and behavioural interventions have produced only moderate improvements. Reviews of trials have suggested that the interventions lack clear theoretical basis, are often compromised by low dose, lack of fidelity, and delivery by non-experts. In addition, interventions do not directly target known risk mechanisms. We identified a theory driven intervention (Contexual Cognitive Behavioural Therapy, CCBT) that directly targets an evidence-based risk mechanism (avoidance and ensured dose and delivery were optimised. This feasibility study was designed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients, and to test recruitment, delivery of the intervention and response rates prior to moving to a full definitive trial.
A randomised controlled feasibility trial with patients randomised to receive CCBT or physiotherapy. CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions. Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based. Patients were eligible to take part if they had back pain for more than 3 months, and scored above a threshold indicating fear avoidance, catastrophic beliefs and distress.
89 patients were recruited. Uptake rates were above those predicted. Scores for credibility and acceptability of the interventions met the set criteria. Response rates at three and six months fell short of the 75 % target. Problems associated with poor response rates were identified and successfully resolved, rates increased to 77 % at 3 months, and 68 % at 6 months. Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity. Numbers were too small for formal analysis. Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy (increase of 7.9 versus 5.1) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group, these findings should be interpreted with caution.
CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery.
ISRCTN43733490 , registered 15/12/2010.
The objectives of this study were to explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon results of multimodal sensory testing, and profile subgroups on demographic, psychological, lifestyle, and general health factors. Bedside (two-point discrimination; brush/vibration/pinprick perception; temporal summation on repeated monofilament stimulation) and laboratory (mechanical detection threshold; pressure/heat/cold pain thresholds; conditioned pain modulation) sensory testing were examined at wrist and lumbar sites. Data were entered into principal component analysis, and five component scores entered into latent class analysis. Three clusters, with different sensory characteristics, were derived. Cluster 1 (31.9%) was characterised by average to high temperature and pressure pain sensitivity. Cluster 2 (52.0%) was characterised by average to high pressure pain sensitivity. Cluster 3 (16.0%) was characterised by low temperature and pressure pain sensitivity. Temporal summation occurred significantly more frequently in Cluster 1. Subgroups were profiled on pain intensity, disability, depression, anxiety, stress, life-events, fear-avoidance, catastrophizing, perception of body schema relating to the back region, comorbidities, body mass index, multiple pain sites, sleep and activity levels. Clusters 1 and 2 had a significantly greater proportion of female participants, and higher depression and sleep disturbance scores than Cluster 3. The proportion of participants undertaking <300 minutes/week of moderate activity was significantly greater in Cluster 1 than Clusters 2 and 3. Low back pain, therefore, does not appear to be homogeneous. Pain mechanisms relating to presentations of each subgroup were postulated. Future research may investigate prognoses and interventions tailored towards these subgroups.
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.
Conventional rehabilitation of patients with chronic pain is often not successful and frustrating for the team. However, theoretical developments and substantial advances in our understanding of the neurological aspects of chronic pain, is changing these experiences. Modern theoretical models of pain consider it a perceptual inference that reflects a 'best guess' that protective action is required. We argue that keen observation, and open and respectful clinician-patient and scientist-clinician relationships, have been critical for the emergence of effective rehabilitation approaches and will be critical for further improvements. We emphasise the role in modern pain rehabilitation of reconceptualising the pain itself by Explaining Pain, careful and intentional observation of the person in pain, and the strategic and constant communication of safety. We also suggest that better understanding of the neural mechanisms underpinning chronic pain has directly informed the development of new therapeutic approaches, which are being further refined and tested. Conventional pain treatment, where the clinician strives to find the pain-relieving medication or exercise, or pain management, where the clinician assists the patient to manage life despite unabating pain, is being replaced by pain rehabilitation, where a truly biopsychosocial approach allows the clinician to provide the patient with the knowledge, understanding and skills to reduce both their pain and disability. We briefly overview the key aspects of modern pain rehabilitation and the considerations that should lead our interaction with patients with chronic pain.
© 2015 American Physical Therapy Association.
What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)?
Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP.
Qualified physiotherapists with experience in treating patients with LBP.
Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions.
Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them.
Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP. Registration: CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of PhysiotherapyXX: XX-XX].
Copyright © 2015. Published by Elsevier B.V.
Pain is a complex problem and one that confronts many physiotherapists' working in private practice on a daily basis. While physiotherapists' understanding of pain has matured a great deal in recent times, especially the role of psychosocial (PS) factors, it is unclear if and how, physiotherapists assess their patients' psychosocial status in clinical practice. The aim of this study was to explore private practice physiotherapists' assessment of patients' psychosocial status.A qualitative descriptive research design was used in this study. Participants were recruited through purposeful sampling and potential informants were invited to participate through letters or phone calls and data was collected via semi-structured interviews. Nine semi-structured interviews were conducted at the participants' workplaces. Data collection and analysis were conducted simultaneously and common concepts and themes were recognised, coded and grouped together into themes.Analysis of the data resulted in identification of various themes related to physiotherapists' assessment of patients' PS status. These themes relate to; physiotherapists capacity to conduct PS assessment, the barriers they face while conducting PS assessment and the suggestions they have provided to overcome these barriers.In general the physiotherapists' in this study demonstrated and acknowledged a poor understanding of the role of PS factors in their patients' clinical presentation. They were also unclear about the assessment of psychosocial factors. The barriers to assessment of psychosocial factors ranged from individual shortcomings to limitations in professional networks and time constraints. The most consistent barrier highlighted was participants' lack of formal education in PS theory and assessment.
It has been proposed that patients with chronic non-specific low back pain (CNSLBP) can be broadly classified based on clinical features that represent either predominantly a mechanical pain (MP) or non-mechanical pain (NMP) profile. The aim of this study was to establish if patients with CNSLBP who report features of NMP demonstrate differences in pain thresholds compared to those who report MP characteristics and pain free controls. This study was a cross sectional design investigating whether pressure pain threshold (PPT) and/or cold pain threshold (CPT) at three anatomical locations differed between patients with mechanical CNSLBP (n = 17) versus non-mechanical CNSLBP (n = 19 and healthy controls (n = 19) whilst controlling for confounders. The results of this study provide evidence of increased CPT at the wrist in the NMP profile group compared to both the MP profile and control subjects, when controlling for gender, sleep and depression (NMP vs MP group Odds Ratio (OR):18.4, 95% CI:2.5 to 133.1, p=0.004). There was no evidence of lowered PPT at any site after adjustment for confounding factors. Those with a MP profile had similar pain thresholds to pain free controls, whereas the NMP profile group demonstrated elevated CPT’s consistent with central amplification of pain. These findings may represent different pain mechanisms associated with these patient profiles and may have implications for targeted management.
Unlabelled:
Scientific models are like tools, and like any tool they can be evaluated according to how well they achieve the chosen goals of the task at hand. In the science of treatment development for chronic pain, we might say that a good model ought to achieve at least 3 goals: 1) integrate current knowledge, 2) organize research and treatment development activities, and 3) create progress. In the current review, we examine models underlying current cognitive behavioral approaches to chronic pain with respect to these criteria. A relatively new model is also presented as an option, and some of its features examined. This model is called the psychological flexibility model. This model fully integrates cognitive and behavioral principles and includes a process-oriented approach of treatment development. So far it appears capable of generating treatment applications that range widely with regard to conditions targeted and modes of delivery and that are increasingly supported by evidence. It has led to the generation of innovative experiential, relationship-based, and intensive treatment methods. The scientific strategy associated with this model seeks to find limitations in current models and to update them. It is assumed within this strategy that all current treatment approaches will one day appear lacking and will change.
Perspective:
This Focus Article addresses the place of theory and models in psychological research and treatment development in chronic pain. It is argued that such models are not merely an academic issue but are highly practical. One potential model, the psychological flexibility model, is examined in further detail.
Emotion and pain are known to be intimately related, but treating co-occurring problems is still in its infancy mainly because we lack a clear theoretical understanding of the underlying mechanisms involved. This lack of understanding is problematic because treatment has proved challenging and co-occurring pain and emotional problems are associated with poor outcome, relapse, and greater sick absenteeism. Transdiagnostics has emerged as one way of focusing on the shared underlying mechanisms that drive comorbid problems. This approach has not been thoroughly examined for pain and emotion. Hence, the purpose of this review is to describe a transdiagnostic approach to pain and emotion and its clinical implications. To this end, the transdiagnostic approach is applied to pain and emotion in a narrative review of the literature. A focus on the function of emotion and pain relative to the context is underscored as a way to understand the relationship better. Avoidance, catastrophic worry, and thought suppression are put forward as three examples of potential transdiagnostic mechanisms that may underlie a co-occurring emotion and pain problem. The approach is readily translated to the clinic where assessment and treatment should focus on identifying transdiagnostic mechanisms. However, additional exploration is needed and therefore suggestions for future research are presented.
Psychological features have been related to trunk muscle activation patterns in low back pain (LBP). We hypothesised higher pain-related fear would relate to changes in trunk mechanical properties, such as higher trunk stiffness.
To evaluate the relationship between trunk mechanical properties and psychological features in people with recurrent LBP.
The relationship between pain-related fear (Tampa Scale for Kinesiophobia, TSK; Photograph Series of Daily Activities, PHODA-SeV; Fear Avoidance Beliefs Questionnaire, FABQ; Pain Catastrophizing Scale, PCS) and trunk mechanical properties (estimated from the response of the trunk to a sudden sagittal plane forwards or backwards perturbation by unpredictable release of a load) was explored in a case-controlled study of 14 LBP participants. Regression analysis (r (2)) tested the linear relationships between pain-related fear and trunk mechanical properties (trunk stiffness and damping). Mechanical properties were also compared with t-tests between groups based on stratification according to high/low scores based on median values for each psychological measure.
Fear of movement (TSK) was positively associated with trunk stiffness (but not damping) in response to a forward perturbation (r(2) = 0.33, P = 0.03), but not backward perturbation (r(2) = 0.22, P = 0.09). Other pain-related fear constructs (PHODA-SeV, FABQ, PCS) were not associated with trunk stiffness or damping. Trunk stiffness was greater for individuals with high kinesiophobia (TSK) for forward (P = 0.03) perturbations, and greater with forward perturbation for those with high fear avoidance scores (FABQ-W, P = 0.01).
Fear of movement is positively (but weakly) associated with trunk stiffness. This provides preliminary support an interaction between biological and psychological features of LBP, suggesting this condition may be best understood if these domains are not considered in isolation.
Observational learning may contribute to development and maintenance of pain-related beliefs and behaviors. The current study examined whether observation of video primes could impact appraisals of potential back stressing activities, and whether this relationship was moderated by individual differences in pain-related fear. Participants viewed a video prime in which back-stressing activity was associated with pain and injury. Both before and after viewing the prime, participants provided pain and harm ratings of standardized movements drawn from the Photograph of Daily Activities Scale (PHODA). Results indicated that observational learning occurred for participants with high levels of pain-related fear but not for low fear participants. Specifically, following prime exposure, high fear participants showed elevated pain appraisals of activity images whereas low fear participants did not. High fear participants appraised the PHODA-M images as significantly more harmful regardless of prime exposure. The findings highlight individual moderators of observational learning in the context of pain.
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.
Despite the profound and pervasive importance of trust in medical settings, there is no commonly shared understanding of what trust means, and little is known about what difference trust actually makes, what factors affect trust, and how trust relates to other similar attitudes and behaviors. To address this gap in understanding, the emerging theoretical, empirical, and public policy literature on trust in physicians and in medical institutions is reviewed and synthesized. Based on this review and additional research and analysis, a formal definition and conceptual model of trust is presented, with a review of the extent to which this model has been confirmed by empirical studies. This conceptual and empirical understanding has significance for ethics, law, and public policy.
We summarize basic empirical themes from studies of adherence to medical regimens and propose a self-regulatory model for conceptualizing the adherence process. The model posits that self-regulation is a function of the representation of health threats and the targets for ongoing coping (symptom reduction, temporal expectancies for change) set by the representation, the procedures to regulate these targets, and the appraisal of coping outcomes. The underlying cognitive mechanism is assumed to function at both a concrete (symptom-based schemata) and abstract level (disease labels), and individuals often engage in biased testing while attempting to establish a coherent representation of a health threat. It also is postulated that cognitive and emotional processes form partially independent processing systems. The coherence of the system, or the common-sense integration of its parts, is seen as crucial for the maintenance of behavioral change. The coherence concept is emphasized in examples applying the model to panic and hypochondriacal disorders.
Background:
Contrasting evidence exists on the ability of clinicians to identify biopsychosocial factors in patients with musculoskeletal pain compared to questionnaires.
Objective:
Evaluate associations between two aspects of clinical practice used to assess biopsychosocial factor contribution in patient presentations (physiotherapist perceptions versus shortened 10-item Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ-10)). Potential influence of physiotherapists' training, experience and confidence level were assessed.
Study design:
Observational.
Methods:
90 musculoskeletal pain patients completed the ÖMPSQ-10 prior to their initial assessment. Independently, 19 treating physiotherapists provided their perception of contribution of biopsychosocial factors to the patient presentation. Pragmatic comparison of physiotherapist perceptions and the ÖMPSQ-10 was made with Spearman's correlations.
Results:
Fair correlation existed between physiotherapists' perception of overall contribution of biopsychosocial factors to the patients' presentation and the ÖMPSQ-10 (0.39). There where moderate correlations for the domains of recovery expectancy (0.53), self-perceived ability to work (0.52) and ability to sleep (0.54). There where fair correlations for anxiety (0.33) and depression (0.32), and a poor correlation for fear (0.10). Correlations were influenced by therapist training in psychosocial aspects of pain, experience and confidence.
Conclusions:
Physiotherapists' perceptions on biopsychosocial contributing factors to overall presentation of patients with musculoskeletal pain were reasonably correlated with a number of the domains in the ÖMPSQ-10. However, correlations for anxiety, depression and fear were not as good. This may reflect a lack of adequate training and/or the inadequacy of single questionnaire items to capture complex issues such as pain-related fear. Screening questionnaires are recommended as an adjunct to clinician perceptions.
Background:
Cognitive Functional Therapy has been shown to reduce pain and disability in people with chronic low back pain.
Objectives:
To investigate participants' experience of Cognitive Functional Therapy by comparing those who reported larger or smaller improvements with treatment, potentially yielding insight into the implementation of this approach.
Design:
Non-interventional, cross-sectional study with an Interpretive Description framework.
Methods:
Individuals who had participated in Cognitive Functional Therapy in two physiotherapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes post intervention (n=9), and theoretical sampling (n=5). This sampling strategy was used to capture a range of participant experiences, but was not used to define the final qualitative groupings. Semi-structured interviews were conducted 3-6 months post intervention.
Results:
Three groups emerged from the qualitative analysis; Large Improvers, Small Improvers and Unchanged. Two themes encapsulated the pivotal steps: (i) Changing Pain Beliefs and (ii) Achieving Independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness and the experience of control over pain. Those who were Unchanged retained their biomedical beliefs. Independence was achieved by Large Improvers through newly cultivated problem solving skills, self-efficacy, decreased fear of pain and improved stress coping. Residual fear and poor stress coping meant Small Improvers were easily distressed and lacked independence. Those who were Unchanged continued to feel defined by their pain and retained a biomedical perspective.
Conclusion:
A successful outcome after Cognitive Functional Therapy is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small Improvers may require ongoing support to maintain results. Further study is required to elucidate the optimal approach for those who were Unchanged.
Objectives:
To explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon data from multiple psychological questionnaires, and profile subgroups on data from multiple dimensions.
Methods:
Psychological questionnaires considered as indicator variables entered into latent class analysis included: Depression, Anxiety, Stress scales, Thought Suppression and Behavioural Endurance subscales (Avoidance Endurance questionnaire), Chronic Pain Acceptance questionnaire (short-form), Pain Catastrophising Scale, Pain Self-Efficacy questionnaire, and Fear-Avoidance Beliefs questionnaire. Multidimensional profiling of derived clusters included: demographics, pain characteristics, pain responses to movement, behaviors associated with pain, body perception, pain sensitivity, and health and lifestyle factors.
Results:
Three clusters were derived. Cluster 1 (23.5%) was characterized by low cognitive and affective questionnaire scores, with the exception of fear-avoidance beliefs. Cluster 2 (58.8%) was characterized by relatively elevated thought suppression, catastrophizing, and fear-avoidance beliefs, but lower pain self-efficacy, depression, anxiety, and stress. Cluster 3 (17.7%) had the highest scores across cognitive and affective questionnaires.Cluster 1 reported significantly lower pain intensity and bothersomeness than other clusters. Disability, stressful life events, and low back region perceptual distortion increased progressively from cluster 1 to cluster 3, whereas mindfulness progressively decreased. Clusters 2 and 3 had more people with an increase in pain following repeated forward and backward spinal bending, and more people with increasing pain following bending, than cluster 1. Cluster 3 had significantly greater lumbar pressure pain sensitivity, more undiagnosed comorbid symptoms, and more widespread pain than other clusters.
Discussion:
Clinical implications relating to presentations of each cluster are postulated.
Fear-avoidance (FA) beliefs are significantly associated with the experience of pain, especially when the pain becomes chronic in nature. The anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors. A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability. Anyone who assesses and treats pain-related disability should also be prepared to assess and treat pain-related FA.
J Orthop Sports Phys Ther 2016;46(2):38–43. doi:10.2519/jospt.2016.0601
Objectives:
Pain-related fear and avoidance of physical activities are central elements of the fear-avoidance model of musculoskeletal pain. Pain-related fear has typically been measured via self-report instruments. In this study, we developed and validated a Behavioral Avoidance Test (BAT) for chronic low back pain (CLBP) patients with the aim of assessing pain-related avoidance behavior via direct observation.
Methods:
The BAT-Back was administered to a group of CLBP patients (N=97) as well as healthy controls (N=31). Furthermore, pain, pain-related fear, disability, catastrophizing, and avoidance behavior were measured using self-report instruments. Reliability was assessed with intraclass correlation coefficient (ICC) and Cronbach's Alpha. Validity was assessed by examining correlation and regression analysis.
Results:
The ICC for the BAT-Back avoidance score was r=0.76. Internal consistency was α=0.95. CLBP patients and healthy controls differed significantly on BAT-Back avoidance scores as well as self-report measures. BAT-Back avoidance scores were significantly correlated with scores on each of the self-report measures (r's=0.27-0.54). They were not significantly correlated with general anxiety and depression, age, body mass index, and pain duration. The BAT-Back avoidance score was able to capture unique variance in disability after controlling for other variables (e.g. pain intensity and pain-related fear).
Discussion:
Results indicate that the BAT-Back is a reliable and valid measure of pain-related avoidance behavior. It may be useful for clinicians in tailoring treatments for chronic pain as well as an outcome measure for exposure treatments.
Background:
Musculoskeletal physiotherapy involves both "specific" and "non-specific" effects. "Non-specific" variables associated with the patient, therapist and setting may influence clinical outcomes. Recent quantitative research has shown that "non-specific" factors including patient-therapist interactions can influence treatment outcomes. It remains unclear however what factors influence patient-therapist interaction.
Purpose:
This qualitative systematic review and meta-synthesis investigated patient and physiotherapist perceptions of factors that influence patient-therapist interaction.
Data sources:
11 databases were searched independently.
Study selection:
Qualitative studies examining physiotherapists' and/or patients' perceptions of factors which influence patient-therapist interaction in musculoskeletal settings were included.
Data extraction:
Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the three stages of analysis; extraction of findings, grouping of findings (codes), abstraction of findings.
Data synthesis:
13 studies were included. Four themes were perceived to influence patient-therapist interactions; (1) Physiotherapist interpersonal and communication skills: presence of skills such as listening, encouragement, confidence, being empathetic and friendly and non-verbal communication; (2) Physiotherapist practical skills: physiotherapist expertise and level of training, while the ability to provide good education was considered as important only by patients; (3) Individualised patient-centred care: individualising the treatment to the patient and taking patient opinions into account and (4) Organisational and environmental factors: time and flexibility with care and appointments.
Limitations:
Only studies published in English were included.
Conclusions:
A mix of interpersonal, clinical and organisational factors are perceived to influence patient-therapist interactions, though research is needed to identify which of these factors do actually influence patient-therapist interactions. Physiotherapist awareness of these factors could enhance patient interactions and treatment outcomes. Mechanisms to best enhance these factors in clinical practice requires further study.
Background and purpose:
Imaging features of spine degeneration are common in symptomatic and asymptomatic individuals. We compared the prevalence of MR imaging features of lumbar spine degeneration in adults 50 years of age and younger with and without self-reported low back pain.
Materials and methods:
We performed a meta-analysis of studies reporting the prevalence of degenerative lumbar spine MR imaging findings in asymptomatic and symptomatic adults 50 years of age or younger. Symptomatic individuals had axial low back pain with or without radicular symptoms. Two reviewers evaluated each article for the following outcomes: disc bulge, disc degeneration, disc extrusion, disc protrusion, annular fissures, Modic 1 changes, any Modic changes, central canal stenosis, spondylolisthesis, and spondylolysis. The meta-analysis was performed by using a random-effects model.
Results:
An initial search yielded 280 unique studies. Fourteen (5.0%) met the inclusion criteria (3097 individuals; 1193, 38.6%, asymptomatic; 1904, 61.4%, symptomatic). Imaging findings with a higher prevalence in symptomatic individuals 50 years of age or younger included disc bulge (OR, 7.54; 95% CI, 1.28-44.56; P = .03), spondylolysis (OR, 5.06; 95% CI, 1.65-15.53; P < .01), disc extrusion (OR, 4.38; 95% CI, 1.98-9.68; P < .01), Modic 1 changes (OR, 4.01; 95% CI, 1.10-14.55; P = .04), disc protrusion (OR, 2.65; 95% CI, 1.52-4.62; P < .01), and disc degeneration (OR, 2.24; 95% CI, 1.21-4.15, P = .01). Imaging findings not associated with low back pain included any Modic change (OR, 1.62; 95% CI, 0.48-5.41, P = .43), central canal stenosis (OR, 20.58; 95% CI, 0.05-798.77; P = .32), high-intensity zone (OR = 2.10; 95% CI, 0.73-6.02; P = .17), annular fissures (OR = 1.79; 95% CI, 0.97-3.31; P = .06), and spondylolisthesis (OR = 1.59; 95% CI, 0.78-3.24; P = .20).
Conclusions:
Meta-analysis demonstrates that MR imaging evidence of disc bulge, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals.
The present study explored the impact of early symptom change (cognitive and behavioural) and the early therapeutic alliance on treatment outcome in cognitive-behavioural therapy (CBT) for the eating disorders. Participants were 94 adults with diagnosed eating disorders who completed a course of CBT in an out-patient community eating disorders service in the UK. Patients completed a measure of eating disorder psychopathology at the start of treatment, following the 6th session and at the end of treatment. They also completed a measure of therapeutic alliance following the 6th session. Greater early reduction in dietary restraint and eating concerns, and smaller levels of change in shape concern, significantly predicted later reduction in global eating pathology. The early therapeutic alliance was strong across the three domains of tasks, goals and bond. Early symptom reduction was a stronger predictor of later reduction in eating pathology than early therapeutic alliance. The early therapeutic alliance did not mediate the relationship between early symptom reduction and later reduction in global eating pathology. Instead, greater early symptom reduction predicted a strong early therapeutic alliance. Early clinical change was the strongest predictor of treatment outcome and this also facilitated the development of a strong early alliance. Clinicians should be encouraged to deliver all aspects of evidence-based CBT, including behavioural change. The findings suggest that this will have a positive impact on both the early therapeutic alliance and later change in eating pathology.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Background and aims: Exposure in vivo for patients with fear-related chronic pain has a strong theoretical base as well as empirical support. However, the treatment does not work for every patient and overall the effect size is only moderate, underscoring the need for improved treatments. One possible way forward might be to integrate an emotion regulation approach since emotions are potent during exposure and because distressing emotions may both interfere with exposure procedures and patient motivation to engage in exposure. To this end, we proposed to incorporate an emotion-regulation focus into the standard exposure in vivo procedure, and delivered in the framework of achieving relevant personal goals. The aim of this study then was to test the feasibility of the method as well as to describe its effects. Method: We tested a hybrid treatment combining an emotion-regulation approach informed by Dialectical Behaviour Therapy (DBT) with a traditional exposure protocol in a controlled, single-subject design where each of the six participants served as its own control. In this design participants first make ratings to establish a baseline from which results during treatment and the five month follow-up may then be compared. To achieve comparisons, participants completed diary booklets containing a variety of standardized measures including pain catastrophizing, pain intensity, acceptance, and function. Results: Compared to baseline, all subjects improved on key variables, including catastrophizing, acceptance, and negative affect, at both post treatment and follow up. For 5 of the 6 subjects considerable gains were also made for pain intensity and physical function. Criteria were established for each measure to help determine whether the improvements were clinically significant. Five of the six participants had consistent results showing clinically significant improvements across all the measures. The sixth participant had mixed results demonstrating improvements on several variables, but not on pain intensity or function. Conclusions: This emotion-regulation hybrid exposure intervention resulted in considerable improvements for the participants. The results of this study underscore the potential utility of addressing emotions in the treatment of chronic pain. Further, they support the idea that targeting emotional stimuli and using emotion regulation skills in conjunction with usual exposure may be important for obtaining the best results. Finally, we found that this treatment is feasible to provide and may be an important addition to usual exposure. However, since we did not directly compare this hybrid treatment with other treatments, additional research is needed before firm conclusions can be made. Implications: Addressing emotional distress in the treatment of patients suffering chronic pain appears to be quite relevant. Emotion regulation skills, employed together with exposure in vivo, hold the promise of being useful tools for achieving better results for patients suffering fear-related and emotionally distressing chronic pain.
Unlabelled:
The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation.
Perspective:
EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.
T here is growing recognition that pain communication is important, and the way that people (eg, partners, health care providers) respond to patients sharing their pain-related thoughts and feelings may have significant implications for pain-related outcomes. 8 One potentially important factor that has been relatively understudied until recently is the level of validation that may or may not be provided by people who are the recipients of a pain communication. 4 Many patients with chronic pain believe that others do not understand their pain or even consider their pain condition to be legitimate, 9 beliefs that are likely to lead to increases in psychological distress and negative affect. It is possible that validation of pain-related thoughts and feelings for these patients may lead to reductions in negative affect. Furthermore, validation from a romantic partner may enhance relationship intimacy, which is related to several positive benefits (eg, increased positive affect, improved psychological well-being). 10,11 Despite the potential benefits of validation, some research suggests that receiving social reinforcement (including validation) after sharing pain-related thoughts and feelings may be associated with worse patient outcomes such as increased pain. 22 This article highlights studies examining the effects of validation of pain-related thoughts and feelings. It is divided into 4 sections. In the first section, we describe the concept of validation. The second section describes several theories that attempt to explain the impact of validation on patient outcomes (eg, affect, report of pain intensity). In the third section, we review a number of studies examining validation and in-validation in the context of pain. In the final section of the article, we highlight several important future directions for research on the influence of validation on chronic pain.
The relevance of a phobia-based conceptualization of fear for individuals with chronic pain has been much debated in the literature. The present study investigated whether highly fearful chronic low back pain (CLBP) patients show distinct physiological reaction patterns compared to less fearful patients when anticipating aversive back pain-related movements. We used an idiosyncratic fear induction paradigm and collected two different measures of autonomic nervous system (ANS) activation as well as muscle tension in the lower back. We identified two distinct psychophysiological response patterns. One pattern was characterized by a moderate increase in skin conductance, inter-beat interval increase, and muscle tension increase in the lower back. This response was interpreted as an attention reaction to a moderately stressful event. The other pattern, found in 58% of the participants, was characterized by a higher skin conductance response, inter-beat interval decrease, and muscle tension increase in the lower back. According to Bradley and Lang´s defense cascade model, this response is typical of a fear reaction. Participants showing the psychophysiological pattern typical of fear also had elevated scores on some self-report measures of components of the fear-avoidance (FA) model, relative to participants showing the reaction pattern characteristic of attention. This is the first study to provide psychophysiological evidence for the fear-avoidance model of chronic pain.
Research has demonstrated that incorporating psychological interventions within physiotherapy practice has numerous potential benefits. Despite this physiotherapists have reported feeling inadequately trained to confidently use such interventions in their day-to-day practice.
To systematically review musculoskeletal physiotherapists' perceptions regarding the use of psychological interventions within physiotherapy practice.
Eligible studies were identified through a rigorous search of AMED, CINAHL, EMBASE, MEDLINE and PsychINFO from January 2002 until August 2013.
Full text qualitative, quantitative and mixed methodology studies published in English language investigating musculoskeletal physiotherapists' perceptions regarding their use of psychological interventions within physiotherapy practice.
Included studies were appraised for risk of bias using the Critical Appraisal Skills Programme qualitative checklist. Meta-analysis was not possible due to study heterogeneity.
Six studies, all with a low risk of bias, met the inclusion criteria. These studies highlighted that physiotherapists appreciate the importance of using psychological interventions within their practice, but report inadequate understanding and consequent underutilisation of these interventions.
These results should be noted with some degree of caution due to various limitations associated with the included studies and with this review, including the use of a qualitative appraisal tool for mixed methodology/quantitative studies.
These findings suggest that musculoskeletal physiotherapists are aware of the potential benefits of incorporating psychological interventions within their practice but feel insufficiently trained to optimise their use of such interventions; hence highlighting a need for further research in this area and a review of physiotherapist training.
Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Objectives:
The Tampa Scale of Kinesiophobia (TSK) has been used to identify people with back pain who have high levels of "fear of movement" to direct them into fear reduction interventions. However, there is considerable debate as to what construct(s) the scale measures. Somatic Focus and Activity Avoidance subscales identified in factor analytic studies remain poorly defined. Using a mixed methods design, this study sought to understand the beliefs that underlie high scores on the TSK to better understand what construct(s) it measures.
Methods:
In-depth qualitative interviews with 36 adults with chronic nonspecific low back pain (average duration=7 y), scoring highly on the TSK (average score=47/68), were conducted. Following inductive analysis of transcripts, individuals were classified into groups on the basis of underlying beliefs. Associations between groups and itemized scores on the TSK and subscales were explored. Frequencies of response for each item were evaluated.
Findings:
Two main beliefs were identified: (1) The belief that painful activity will result in damage; and (2) The belief that painful activity will increase suffering and/or functional loss. The Somatic Focus subscale was able to discriminate between the 2 belief groups lending construct validity to the subscale. Ambiguous wording of the Activity Avoidance subscale may explain limitations in discriminate ability.
Discussion:
The TSK may be better described as a measure of the "beliefs that painful activity will result in damage and/or increased suffering and/or functional loss."
Even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory. Exercise therapy for patients with chronic musculoskeletal pain is often hampered by such pain memories. Here the authors explain how musculoskeletal therapists can alter pain memories in patients with chronic musculoskeletal pain, by integrating pain neuroscience education with exercise interventions. The latter includes applying graded exposure in vivo principles during exercise therapy, for targeting the brain circuitries orchestrated by the amygdala (the memory of fear centre in the brain).
Before initiating exercise therapy, a preparatory phase of intensive pain neuroscience education is required. Next, exercise therapy can address movement-related pain memories by applying the ‘exposure without danger’ principle. By addressing patients’ perceptions about exercises, therapists should try to decrease the anticipated danger (threat level) of the exercises by challenging the nature of, and reasoning behind their fears, assuring the safety of the exercises, and increasing confidence in a successful accomplishment of the exercise. This way, exercise therapy accounts for the current understanding of pain neuroscience, including the mechanisms of central sensitization.
Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).
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.
The design of this study was a systematic review.
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.
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.
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.
Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.
Study Design. An integrated review of current knowledge about the biopsychosocial model of back pain for understanding aetiology, prognosis and interventions, as presented at the plenary sessions of theXII International Forum on LBP Research in Primary Care (Denmark 17-19 October 2012).Objective. To evaluate the utility of the model in reference to rising rates of back pain related disability, by identifying a) the most promising avenues for future research in biological, psychological and social approaches, b) promising combinations of all three approaches and c) obstacles to effective implementation of biopsychosocial based research and clinical practice.Summary of Background Data. The biopsychosocial model of back pain has become a dominant model in the conceptualisation of the aetiology and prognosis of back pain, and has led to the development and testing of many interventions. Despite this back pain remains a leading source of disability worldwide.Methods. The review is a synthesis based on the plenary sessions and discussions at the XII International Forum on LBP Research in Primary Care. The presentations included evidence-based reviews of the current state of knowledge in each of the three areas (biological, psychological and social), identification of obstacles to effective implementation and missed opportunities, and identification of the most promising paths for future research.Results. While there is good evidence for the role of biological, psychological and social factors in the aetiology and prognosis of back pain, synthesis of the three in research and clinical practice has been suboptimal.Conclusion. The utility of the biopsychosocial framework cannot be fully assessed until we truly adopt and apply it in research and clinical practice.
In the context of uncertainty about aetiology and prognosis, good clinical practice commonly recommends both affective (creating rapport, showing empathy) and cognitive reassurance (providing explanations and education) to increase self-management in groups with non-specific pain conditions. The specific impact of each of these components in reference to patients' outcomes has not been studied. This review aimed to systematically evaluate the evidence from prospective cohorts in primary care that measured patient-practitioner interactions with reference to patient outcomes. We carried out a systematic literature search and appraisal of study methodology. We extracted measures of affective and cognitive reassurance in consultations and their associations with consultation-exit and follow up measures of patients' outcomes. We identified 16 studies from 16,059 abstracts. Eight studies were judged to be high in methodological quality. Pooling could not be achieved due to heterogeneity of samples and measures. Affective reassurance showed inconsistent findings with consultation exit outcomes. In three high-methodology studies, an association was found between affective reassurance and higher symptom burden and less improvement at follow up. Cognitive reassurance was associated with higher satisfaction and enablement and reduced concerns directly after the consultations in eight studies; with improvement in symptoms at follow up in seven studies; and with reduced health care utilization in three studies. Despite limitations, there is support for the notion that cognitive reassurance is more beneficial than affective reassurance. We present a tentative model based on these findings and propose priorities for future research.
Within a biopsychosocial framework, psychological factors are thought to play an important role in the onset and progression of chronic pain. The cognitive-behavioral fear-avoidance model of chronic pain suggests that pain-related fear contributes to the development and maintenance of pain-related disability. However, investigations of the relation between pain-related fear and disability have demonstrated considerable between-study variation. The main goal of the current meta-analysis was to synthesize findings of studies investigating cross-sectional associations between pain-related fear and disability in order to estimate the magnitude of this relation. We also tested potential moderators, including type of measure used, demographic characteristics, and relevant pain characteristics. Searches in PubMed and PsycINFO yielded a total of 46 independent samples (N = 9,579) that reported correlations between pain-related fear and disability among persons experiencing acute or chronic pain. Effect size estimates were generated using a random-effects model and artifact distribution method. The positive relation between pain-related fear and disability was observed to be moderate to large in magnitude, and stable across demographic and pain characteristics. Although some variability was observed across pain-related fear measures, results were largely consistent with the fear-avoidance model of chronic pain.
Results of this meta-analysis indicate a robust, positive association between pain-related fear and disability, which can be classified as moderate to large in magnitude. Consistent with the fear-avoidance model of chronic pain, these findings suggest that pain-related fear may be an important target for treatments intended to reduce pain-related disability.
This immensely practical volume describes the rationale, development, and utilization of cognitive-behavioral techniques in promoting health, preventing disease, and treating illness, with a particular focus on pain management. An ideal resource for a wide range of practitioners and researchers, the book's coverage of pain management includes theoretical, research, and clinical issues, and includes illustrative case material.
The purpose of the article is to summarize evidence and recommendations for psychological interventions in the rehabilitation of patients with chronic low back pain. We carried out a systematic literature search in several databases and on the websites of professional associations to identify relevant reviews and guidelines. In addition to the electronic search, a handsearch was carried out. Eligible publications were selected. We extracted and summarized both evidence for psychological interventions and recommendations on psychological diagnostics and interventions. Six systematic reviews and 14 guidelines were included. We collected recommendations and partially restricted evidence on the following psychological interventions: behavioural therapy, fear-avoidance training, stress management, relaxation therapy, patient education and back school. Most available evidence for psychological interventions in the rehabilitation of patients with chronic low back pain is of moderate to low quality. In addition, some of the older evidence is inapplicable to modern interventions using a biopsychosocial approach. Thus, high quality and current evidence is needed. The summary of guidelines shows that multimodal, multidisciplinary programmes including psychological interventions have become standard in the rehabilitation of patients with chronic low back pain. In most guidelines, however, there are no recommendations on which (psychological) intervention should be considered for which specific problem (problem-treatment pairs). Suggestions for future research and future guidelines are made.
Background:
The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been previously investigated.
Objective:
The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes.
Design:
This was a retrospective observational study nested within a randomized controlled trial.
Methods:
One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment.
Results:
The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures.
Limitations:
Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.
Conclusions:
Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.
Study design:
Single-site, exploratory, cross-sectional design.
Objective:
To identify variables associated with disability related to low back pain (LBP), as measured by the modified Oswestry Low Back Pain Disability Questionnaire (mOSW), in a sample of working adults with nonacute LBP.
Background:
Compared to acute LBP, there is little information available in the literature to identify variables associated with LBP-related disability in working individuals with stage 2 and stage 3 LBP.
Methods:
Data analyzed were from working individuals with nonacute LBP (n = 235). The response variable was dichotomized by mOSW score (less than 20 or 20 or greater), and the regressor variables included 27 self-report, sociodemographic, impairment-based, and kinematic measures used to assess individuals with LBP. Logistic regression was used to identify variables associated with mOSW.
Results:
One hundred eleven subjects had a mOSW score of 20 or greater, and 124 subjects had a mOSW score of less than 20. Logistic regression analysis identified 4 variables associated with LBP-related disability (mOSW): duration of LBP (P = .006), numeric pain rating (P<.0001), Fear-Avoidance Beliefs Questionnaire physical activity subscale (P = .0007), and limits of stability movement velocity in the forward direction (P = .02). The best model had an R2(u) of 0.25.
Conclusion:
The odds of LBP-related disability (mOSW) in this sample of nonacute working individuals were found to increase with longer duration of LBP, higher numeric pain rating scores, higher Fear-Avoidance Beliefs Questionnaire physical activity subscale scores, and slower limits of stability movement velocity in the forward direction. The identification of limits of stability movement velocity is a novel finding that may support a link between sensorimotor balance deficits and disability in working individuals with nonacute LBP.
The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability.
A narrative review.
There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals.
To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.