994 IS GRADED EXPOSURE IN VIVO COST‐EFFECTIVE? AN ECONOMIC EVALUATION STUDY IN CHRONIC LOW BACK PAIN

BACKGROUND Chronic low back pain (cLBP) can interfere with daily activities, and individuals with elevated pain-related fear (also known as kinesiophobia or the fear of injury due to movement) can develop worse long-term disability. Graded exposure (GEXP) protocols use successive participation in avoided activities to help individuals overcome fearful movement appraisals and encourage activity. We sought to develop a series of GEXP virtual reality (VR) walking and reaching scenarios to increase the exposure and engagement of people with high kinesiophobia and cLBP. OBJECTIVE This study aims to (1) determine GEXP content validity of the VR application and (2) determine the feasibility of individuals with cLBP performing locomotion-enabled physical activities. METHODS We recruited 13 individuals with cLBP and high pain-related fear to experience six VR modules, which provide progressive movement exposure over three sessions in a 1 week period. At session 1, participants ranked each module by likelihood to avoid and assigned an expected pain and concern for harming their back rating to each module. Participants provided a rating of perceived exertion (RPE) after experiencing each module. To test feasibility, we administered the system usability scale (SUS) and treatment evaluation inventory (TEI) following the final session. In addition, we measured pain and pain-related fear at baseline and follow-up. RESULTS The 12 participants who completed the study period assigned higher avoidance (P=.002), expected pain (P=.002), and expected concern (P=.002) for session 3 modules compared with session 1 modules. RPE significantly increased from session 1 (mean 14.8, SD 2.3) to session 3 (mean 16.8, SD 2.2; P=.009). The VR application showed positive feasibility for individuals with cLBP through acceptable SUS (mean 76.7, SD 13.0) and TEI (mean 32.5, SD 4.9) scores. Neither pain (P=.20) nor pain-related fear (P=.58) changed significantly across sessions. CONCLUSIONS The GEXP VR modules provided progressive exposure to physical challenges, and participants found the VR application acceptable and usable as a potential treatment option. Furthermore, the lack of significant change for pain and pain-related fear reflects that participants were able to complete the modules safely.

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Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain: A Systematic Review

Physical Therapy ◽

10.2522/ptj.20090303 ◽

2010 ◽

Vol 90 (6) ◽

pp. 860-879 ◽

Cited By ~ 87

Author(s):

Luciana G. Macedo ◽

Rob J.E.M. Smeets ◽

Christopher G. Maher ◽

Jane Latimer ◽

James H. McAuley

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Confidence Intervals ◽

Controlled Trials ◽

Low Back ◽

Short Term ◽

Minimal Intervention ◽

Randomized Controlled ◽

Graded Exposure ◽

Graded Activity

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

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