Telerehabilitation of acute musculoskeletal multi-disorders: prospective, single-arm, interventional study

Background Acute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability. Objective Present the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas. Methods Interventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement. Results Three hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean − 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26). Strengths and limitations This is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group. Conclusions We observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care. Trial registration NCT, NCT04092946. Registered 17/09/2019;

Psychological Approaches for the Integrative Care of Chronic Low Back Pain: A Systematic Review and Metanalysis

Chronic low back pain (CLBP) is the most common cause of disability worldwide, affecting about 12% to 30% of the adult population. Psychological factors play an important role in the experience of pain, and may be predictive of pain persistence, disability, and long-term sick leave. The aim of this meta-analysis was to identify and to describe the most common psychological approaches used to treat patients who suffer from CLBP. A systematic search was performed on PubMed/MEDLINE and Cochrane Central. Overall, 16 studies with a total of 1058 patients were included in the analysis. Our results suggest that cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) interventions are both associated with an improvement in terms of pain intensity and quality of life when singularly compared to usual care. Disability also improved in both groups when compared to usual care. Significant differences in fear-avoidance beliefs were noted in the CBT group compared to usual care. Therefore, psychological factors are related to and influence CLBP. It is crucial to develop curative approaches that take these variables into account. Our findings suggest that CBT and MBSR modify pain-related outcomes and that they could be implemented in clinical practice.

Measurement properties of the Brazilian versions of Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in individuals with shoulder pain

Purpose To verify the measurement properties of the Brazilian versions of Fear-avoidance Beliefs Questionnaire (FABQ) and Tampa Scale of Kinesiophobia (TSK) in individuals with shoulder pain. Methods Individuals with shoulder pain (>18 years) were included in this study. Structural validity was verified by exploratory factor analysis, which was used to identify dimensionality of the FABQ and TSK. Test-retest reliability was assessed with intraclass correlation coefficient(3,1) and internal consistency with Cronbach’s alpha. Floor or ceiling effects were also investigated. Responsiveness was verified by effect sizes and area under the receiver operating characteristic curve (AUC). Results Exploratory factor analysis identified two and one factor in the FABQ and TSK, respectively. FABQ and TSK presented moderate to good reliability and adequate internal consistency (Cronbach’s alpha > 0.70). The floor effect was present in one factor of the FABQ. The FABQ and TSK showed small to moderate effect sizes and did not show adequate AUC. Conclusion FABQ and TSK are multidimensional and unidimensional instruments, respectively. Those instruments presented moderate to good reliability and the responsiveness was considered to be suboptimal in individuals with shoulder pain.

Development of the Prevent for Work Questionnaire (P4Wq) for the assessment of musculoskeletal risk factors in the workplace: part 2—pilot study for questionnaire development and validation

ObjectiveThe aim of this study was to develop a multifactorial, self-report questionnaire: Prevent for Work Questionnaire (P4Wq). The questionnaire is intended for screening for risk factors in work-related musculoskeletal disorders (WMSDs).DesignData were collected from otherwise healthy workers employed in three service areas at a specialist hospital in Italy: healthcare, administration and ancillary services.Setting and participantsIn all, 115 participants were enrolled (67% women; average age 41.5±9.94 years). The content of the tool for WMSDs was derived from three participation rounds of analysis involving a select group of experts who identified the questionnaire domains and items. Participants responded to 89 items in addition to the EuroQol 5 Dimensions Questionnaire (EQ-5D-5L), Fear-Avoidance Beliefs Questionnaire (FABq) and Oswestry Disability Index (ODI). The proportion of missing data and the distribution of responses were analysed for each item. Items with a discrimination index >0.40 and an interitem correlation <0.80 were retained. Factor analysis was performed using the VARIMAX rotation method, factor extraction, and identification, assignment of items to subscales, and assignment of scores to items. Internal consistency, reliability, construct validity and face validity were also assessed.ResultsA total of 52 items were included in the factor analysis and four subscales identified: Physical Stress Subscore (six items); Mental Stress Subscore (six items); Job Satisfaction Subscore (four items) and Kinesiophobia/Catastrophizing Subscore (four items). The items in the final questionnaire version had a factor loading >0.7. The questionnaire consisted of 20 items with good internal consistency (Cronbach’s alpha 0.81–0.91), reliability (weighted kappa coefficient 0.617–1.00), good construct validity (EQ-5D-5L, r=−0.549, p<0.001; ODI, r=0.549, p<0.001; FABq work, r=0.688, p<0.001) and satisfactory face validity (universal validity index 96.04%).ConclusionThe P4Wq is a 20-item, multifactorial self-report risk assessment questionnaire. It may provide a useful tool for screening for WMSDs by specifically addressing back disorders. It investigates risks for individual workers and may inform educational programmes and preventive strategies tailored to a worker’s needs.Trial registration numberNCT04192604

Effectiveness of behavioural medical rehabilitation under real-life conditions in germany: a propensity-score matched analysis

Objectives: In Germany, behavioural medical rehabilitation programmes have been implemented for patients with musculoskeletal disorders and additional mental health comorbidity. The aim of this cohort study is to assess the relative effectiveness of behavioural medical rehabilitation under real-life conditions. Design: Participants received either a common or behavioural medical rehabilitation programme. Propensity score matching was used to provide balanced samples of both groups (German Clinical Trials Register: DRKS00016404). Participants: A total of 360 patients treated in behavioural medical rehabilitation were compared with 360 matched controls. The mean age of study participants was approximately 53.5 years (standard deviation (SD)=7.0 years) and 74.0% were women. Results: No significant and clinical meaningful differences were found in return to work, applications for disability pension, and the number of patients receiving social security benefits in the year after rehabilitation. However, participants in behavioural medical rehabilitation reported better self-rated work ability, physical functioning and self-management skills, and decreased pain disability and fear-avoidance beliefs 10 months after rehabilitation. Standardized effect sizes were between 0.13 and 0.22. Conclusion: Behavioural medical rehabilitation had no clinical meaningful effect on maintaining and restoring work ability. However, behavioural medical rehabilitation affected pain and disease management skills 10 months after completing the rehabilitation programme.

The Prediction of Chronicity in Patients with Acute and Sub-Acute Non-Specific Low Back Pain and Associated Risk Factors: A Case-Control Study

Background: Chronic low back pain is one of the most common musculoskeletal disorders in different countries that people of any age can experience many times. This study aimed to predict the chronicity of non-specific acute and sub-acute LBP and related risk factors among cases referred to physiotherapy clinics.Methods: This case-control study was performed among 420 patients suffered from acute, sub-acute and chronic LBP referred to two physiotherapy centers in Tehran-Iran in 2020. Data were obtained using the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Pain Catastrophic Scale (PCS-13), Tampa Scale for Kinesiophobia (TSK-11), Pittsburgh Sleep Quality Index (PSQI), Walker's Health-Promoting Lifestyle Questionnaire, Roland Morris Disability Questionnaire (RMDQ) and Numerical Pain Rating Scale (NPRS). Data analysis was performed by applying independent sample t-test, chi-square, and multiple logistic regression in SPSS software version 25. IBM Amos version 22 was employed for path analysis.Results: The mean age and body mass index in all patients were 43.94 ± 6.72 years and 25.69 ± 3.54 kg.m-2, respectively. It was found that some demographic parameters (i.e. weight, BMI, job, type of occupational task performance, history of low back pain, work shift, underlying diseases and income), some cognitive parameters ( i.e. fear-avoidance beliefs, kinesiophobia, catastrophic pain, and depression), some lifestyle parameters (i.e. health responsibility, physical activity and interpersonal relationships), sleep quality and pain related disability were among the most critical risk factors in the chronicity of acute and sub-acute LBP (P < 0.05).Conclusion: Personal, psychological, and psychosocial parameters can be among the most critical predictors in the chronicity of acute and sub-acute non-specific LBP. Hence, paying attention to all the mentioned factors at the beginning of patients' treatment to create a targeted treatment algorithm and prevent the conversion of acute and sub-acute into chronic LBP has particular importance.

Changes in Pain Catastrophizing and Fear-Avoidance Beliefs as Mediators of Early Physical Therapy on Disability and Pain in Acute Low-Back Pain: A Secondary Analysis of a Clinical Trial

Objective The Fear-Avoidance Model of chronic pain (FAM) posits that pain catastrophizing and fear-avoidance beliefs are prognostic for disability and chronicity. In acute low-back pain, early physical therapy (PT) is effective in reducing disability in some patients. How early PT impacts short- and long-term changes in disability for patients with acute pain is unknown. Based on the FAM, we hypothesized that early reductions in pain catastrophizing and fear-avoidance beliefs would mediate early PT’s effect on changes in disability (primary outcome) and pain intensity (secondary outcome) over 3 months and 1 year. Subjects Participants were 204 patients with low-back pain of &lt; 16 days duration, who enrolled in a clinical trial (NCT01726803) comparing early PT sessions or usual care provided over 4 weeks. Methods Patients completed the Pain Catastrophizing Scale (PCS), Fear-Avoidance Beliefs Questionnaire (FABQ work and physical activity scales) and outcomes (Oswestry Disability Index and Numeric Pain Rating Scale) at baseline, 4 weeks, 3 months, and 1 year. We applied longitudinal mediation analysis with single and multiple mediators. Results Early PT led to improvements in disability and pain over 3 months, but not 1 year. In the single mediator model, four-week reductions in pain catastrophizing mediated early PT’s effects on 3-month disability and pain intensity improvements, explaining 16% and 22% of the association, respectively, but the effects were small. Pain catastrophizing and fear-avoidance beliefs did not jointly mediate these associations. Conclusions In acute low-back pain, early PT may improve disability and pain outcomes at least partly through reducing patients’ catastrophizing.