Fear-avoidance Beliefs Research Articles

Can a Psychologic Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury?

Psychologic variables have been shown to have a strong relationship with recovery from injury and return to work or sports. The extent to which psychologic variables predict successful return to work in military settings is unknown. In a population of active duty soldiers, (1) can a psychologic profile determine the risk of injury after return to full duty? (2) Do psychologic profiles differ between soldiers sustaining injuries in the spine (thoracic or lumbar) and those with injuries to the lower extremities? Psychologic variables were assessed in soldiers returning to full, unrestricted duty after a recent musculoskeletal injury. Most of these were noncombat injuries from work-related physical activity. Between February 2016 and September 2017, 480 service members who were cleared to return to duty after musculoskeletal injuries (excluding those with high-velocity collisions, pregnancy, or amputation) were enrolled in a study that tracked subsequent injuries over the following year. Of those, we considered individuals with complete 12-month follow-up data as potentially eligible for analysis. Based on that, approximately 2% (8 of 480) were excluded because they did not complete baseline surveys, approximately 2% (11 of 480) were separated from the military during the follow-up period and had incomplete injury data, 1% (3 of 480) were excluded for not serving in the Army branch of the military, and approximately 2% (8 of 480) were excluded because they were not cleared to return to full duty. This resulted in 450 soldiers analyzed. Individuals were 86% (385 of 450) men; 74% (331 of 450) had lower extremity injuries and 26% (119 of 450) had spinal injuries, including soft tissue aches and pains (for example, strains and sprains), fractures, and disc herniations. Time-loss injury within 1 year was the primary outcome. While creating and validating a new prediction model using only psychological variables, 19 variables were assessed for nonlinearity, further factor selection was performed through elastic net, and models were internally validated through 2000 bootstrap iterations. Performance was deciphered through calibration, discrimination (area under the curve [AUC]), R 2 , and calibration in the large. Calibration assesses predicted versus actual risk by plotting the x and y intersection of these values; the more similar predicted risk values are to actual ones, the closer the slope of the line formed by the intersection points of all subjects is to equaling "1" (optimal calibration). Likewise, perfect discrimination (predicted injured versus actual injured) presents as an AUC of 1. Perfect calibration in the large would equal 0 because it represents the average predicted risk versus the actual outcome rate. Sensitivity analyses stratified groups by prior injury region (thoracic or lumbar spine and lower extremity) as well as the severity of injury by days of limited duty (moderate [7-27 days] and severe [28 + days]). A model comprising primarily psychologic variables including depression, anxiety, kinesiophobia, fear avoidance beliefs, and mood did not adequately determine the risk of subsequent injury. The derived logistic prediction model had 18 variables: R 2 = 0.03, calibration = 0.63 (95% confidence interval [CI] 0.30 to 0.97), AUC = 0.62 (95% CI 0.52 to 0.72), and calibration in the large = -0.17. Baseline psychologic profiles between body regions differed only for depression severity (mean difference 1 [95% CI 0 to 1]; p = 0.04), with greater mean scores for spine injuries than for lower extremity injuries. Performance was poor for those with prior spine injuries compared with those with lower extremity injuries (AUC 0.50 [95% CI 0.42 to 0.58] and 0.63 [95% CI 0.57 to 0.69], respectively) and moderate versus severe injury during the 1-year follow-up (AUC 0.61 [95% CI 0.51 to 0.71] versus 0.64 [95% CI 0.64 to 0.74], respectively). The psychologically based model poorly predicted subsequent injury. This study does not minimize the value of assessing the psychologic profiles of injured athletes, but rather suggests that models looking to identify injury risk should consider a multifactorial approach that also includes other nonpsychologic factors such as injury history. Future studies should refine the most important psychologic constructs that can add the most value and precision to multifactorial models aimed at identifying the risk of injury. Level III, prognostic study.

Examining Psychological Factors as Contributors to Pain, Disability, and Physical Function in Geriatric Chronic Low Back Pain: A Prospective Analysis of the Delaware Spine Studies Cohort

In younger populations, risk factors from psychologically-focused theoretical models have become accepted as primary drivers behind the persistence of low back pain (LBP), but these risk factors have not been thoroughly assessed in older adult populations (60–85 years). To address this knowledge gap, we sought to examine longitudinal associations between both general and pain-related psychological risk factors and future pain intensity, LBP-related disability, and physical function (gait speed) outcomes in older adults with chronic LBP (n = 250). Questionnaires for general (ie, depressive symptoms) and pain-related psychological risk factors (ie, fear-avoidance beliefs, pain catastrophizing, and kinesiophobia) were collected at baseline. Questionnaire values were entered into principal component analysis to yield a combined psychological component score. LBP intensity (pain thermometers), LBP-related disability (Quebec Back Pain Disability Scale), and gait speed were measured at baseline and 12-month follow-up. Multiple linear regression was used to examine adjusted associations between baseline psychological component scores and each prospective outcome. The baseline psychological component score failed to independently predict 12-month LBP-related disability and gait speed after adjustment for baseline outcomes. Though the psychological component score was associated with 12-month LBP intensity after adjusting for baseline LBP intensity, this association diminished with full adjustment for other baseline characteristics. Cumulatively, general and pain-related psychological risk factors did not independently predict longitudinal pain, disability, and physical function outcomes in this cohort. Compared to younger populations with this condition, general and pain-related psychological risk factors may have less influence on the maintenance of chronic LBP in older adults. PerspectiveThis article failed to establish consistent independent relationships between psychological factors and worse longitudinal pain, disability, and physical function outcomes in older adults with chronic LBP. The findings highlight a need to determine other age-specific biopsychosocial risk factors that may impact the maintenance of chronic pain in this patient population.

Effect of multidimensional physiotherapy on non-specific chronic low back pain: a randomized controlled trial

BackgroundMany people with non-specific chronic low back pain (NSCLBP) do not recover with current conventional management. Systematic reviews show multidimensional treatment improves pain better than usual active interventions. It is unclear whether multidimensional physiotherapy improves pain better than usual physiotherapy. This study determines the effectiveness of this treatment to reduce pain and disability and improve quality of life, pain cognitions, and electroencephalographic pattern in individuals with NSCLBP.Methods70 eligible participants aged 18 to 50 years with NSCLBP were randomized into either the experimental group (multidimensional physiotherapy) or the active control group (usual physiotherapy). Pain intensity was measured as the primary outcome. Disability, quality of life, pain Catastrophizing, kinesiophobia, fear Avoidance Beliefs, active lumbar range of motion, and brain function were measured as secondary outcomes. The outcomes were measured at pre-treatment, post-treatment, 10, and 22 weeks. Data were analyzed using intention-to-treat approaches.ResultsThere were 17 men and 18 women in the experimental group (mean [SD] age, 34.57 [6.98] years) and 18 men and 17 women in the active control group (mean [SD] age, 35.94 [7.51] years). Multidimensional physiotherapy was not more effective than usual physiotherapy at reducing pain intensity at the end of treatment. At the 10 weeks and 22 weeks follow-up, there were statistically significant differences between multidimensional physiotherapy and usual physiotherapy (mean difference at 10 weeks, -1.54; 95% CI, -2.59 to -0.49 and mean difference at 22 weeks, -2.20; 95% CI, − 3.25 to − 1.15). The standardized mean difference and their 95% confidence intervals (Cohen’s d) revealed a large effect of pain at 22 weeks: (Cohen’s d, -0.89; 95% CI (-1.38 to-0.39)). There were no statistically significant differences in secondary outcomes.ConclusionsIn this randomized controlled trial, multidimensional physiotherapy resulted in statistically and clinically significant improvements in pain compared to usual physiotherapy in individuals with NSCLBP at 10 and 22 weeks.Trial RegistrationClinicalTrials.gov NCT04270422; IRCT IRCT20140810018754N11.

Fear avoidance beliefs, anxiety, and depression in healthy individuals and persons with vestibular disorders across cultures.

In persons with vestibular disorders, disturbed vestibular input and accompanying dizziness can be associated with anxiety or depression. To avoid dizziness, persons with vestibular disorders can develop mal-adaptive fear avoidance behaviors which can negatively influence daily life functioning. The aims of this study were to (1) document different psychological factors in patients with vestibular disorders and healthy adults across cultures and (2) to assess the convergent validity of the 9-item Vestibular Activities Avoidance Instrument (VAAI), which quantifies fear avoidance beliefs. Psychological factors and disability were measured in Dutch-speaking healthy adults and English- and Dutch-speaking persons with vestibular disorders using the VAAI, the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS) and the Activities-Specific Balance Confidence Scale (ABC). The convergent validity of the VAAI was investigated by performing correlation analyses between the VAAI, the DHI, the HADS, and the ABC. A total of 151 Dutch-speaking healthy adults, 404 English-speaking participants with vestibular disorders, and 126 Dutch-speaking participants with vestibular disorders were included. Participants with vestibular disorders presented with higher levels of fear avoidance beliefs (VAAI), perceived disability (DHI), anxiety and depression (HADS), and lower confidence during balance activities (ABC) compared to healthy adults. Regarding the convergent validity of the VAAI, there were moderate to strong correlation coefficients (r = 0.39-0.74) between fear avoidance and the DHI, HADS, and ABC in participants with vestibular disorders. Participants with vestibular disorders report a higher psychological burden compared to healthy adults. These results emphasize the importance of assessing psychological factors in persons with vestibular disorders. In addition, evidence was provided for convergent validity, supporting the VAAI as a valid outcome measure across cultures.

Predicting outcomes across treatment settings in patients with shoulder pain referred to physiotherapy: a secondary analysis of two comparable prospective cohort studies

ObjectivePrevious studies have examined factors that may contribute to predicting outcomes for patients with shoulder pain. However, there is still a lack of consensus on which factors predict the results...

Validation and reliability testing of the "Athlete Fear Avoidance Questionnaire (AFAQ)"

Sports injuries may have severe implications for an athlete's career. Psychological factors play an important role on an athlete's journey from the injury to the return to competitive sports. These factors are often insufficiently evaluated, which may lead to prolonged downtime. The Athlete Fear Avoidance Questionnaire (AFAQ) may be used to measure fear avoidance patterns in injured athletes. There is no validated German version of the questionnaire at this time. This study aims to evaluate the test-retest reliability, internal consistency and construct validity of the transculturally translated German version of the AFAQ (AFAQ_D) in injured athletes. The German version of the AFAQ_D was translated using the TRAPD model. Construct validity was evaluated with correlations to the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale for Kinesiophobia (TSK). Internal consistency was calculated using Cronbach's Alpha, while the interclass coefficient was used to calculate test-retest reliability. This study included 64 athletes aged 16 to 36 years (Ø 23.15 years, ♀ 17%, ♂ 83%) after a variety of injuries. The AFAQ_D yielded good reliability values with Crohnbach's Alpha being 0.76 (95%CI; 0.67-0.84) in the first measurement and 0.82 (95%CI; 0.76-0.88) in the second measurement, and the interclass coefficient being 0.798 (95%CI; 0.674-0.876). Regarding validity, a moderate correlation was found between the AFAQ_D and the TSK (r=0.57, p<0.01), and a weak and non-significant correlation was found between the AFAQ_D and the FABQ (r=0.13, p=0.31). By and large, the German version of the AFAQ is a valid and reliable questionnaire to evaluate fear avoidance as well as the psychological readiness of athletes after an injury. Correlations with TSK and FABQ are roughly comparable with the original study.

Assessment of Long-term Effects of Adding Osteopathic Manipulative Treatment to Neck Exercises for Individuals With Non-specific Chronic Neck Pain: A Randomized Trial

ObjectiveThe purpose of this study was to evaluate the long-term effects of adding osteopathic manipulative treatment (OMT) to neck exercises compared to exercises alone for individuals with non-specific chronic neck pain (NCNP). MethodsA randomized controlled trial was conducted by assigning 90 individuals with NCNP into the following 2 groups: (1) exercises group (EG, n = 45) or (2) OMT plus exercises group (OMT/EG, n = 45). All participants received 4 weeks of treatment. The clinical outcomes were recorded at baseline and at 3 and 6 months after the treatment. The primary outcomes were pain and function—Numerical Pain Rating Scale (NPRS), Pressure Pain Threshold, and the Neck Disability Index (NDI). The secondary outcomes included range of motion for cervical spine rotation, Fear-Avoidance Beliefs Questionnaire, and Pain Self-Efficacy Questionnaire. ResultsIn comparison to baseline data, both groups had a reduction of NPRS (P < .05) and NDI (P < .05) after the treatment. However, no statistically significant differences in pain intensity or disability were found when OMT/EG was compared to EG alone at 3 months (P = 0.1 and P = 0.2, respectively) and at 6 months (P = 0.4 and P = 0.9, respectively for pain and disability) and no difference was found between OMT/EG and the EG in the secondary outcomes during the same follow-up period (P > .05). ConclusionOutcomes of pain and functionality for patients in both groups were improved at 6 months. Our findings show that the combination of OMT and neck exercises for 4 weeks did not improve functionality and reduction of pain in patients with NCNP.

Contextual factors in persistent severe back pain: A longitudinal analysis among German employees.

Chronic back pain in employees compromises participation in social and daily activities, as well as work. To examine the severity of back pain after 2 years and identify factors predicting stagnation at this level of pain. Data were derived from a prospective cohort study with randomized sampling of insurants in the German Pension Insurance using a questionnaire at baseline and follow-up after 2 years. The sample consisted of middle-aged employees (45-59 years) with strong limitations due to back pain (Chronic Pain Grade III or IV), who had not applied for disability pension and did not use medical rehabilitation in the previous 4 years before baseline. Stepwise multivariable logistic regression models with backwards selection were used to identify relevant contextual factors in the stagnation of severe back pain. Of 1208 persons with severe back pain at baseline, 48% had stagnated at that pain level after 2 years. Predictors of persistent severe back pain were older age, poorer general health, more additional disabling conditions, more depressive symptoms, caregiving burden, less pain-related self-efficacy and more fear avoidance beliefs. In a high-risk subgroup with several co-existing conditions, this analysis highlights (mental) health, social and personal (contextual) factors associated with long-term unfavourable back pain progression. Back pain is a condition that often has a chronic or recurrent course, threatening participation in many areas of life. In this study it was found that the unfavourable condition of severe back pain can remain stable for long periods of time in a significant proportion of sufferers. Contextual factors (self-efficacy, fear-avoidance beliefs, caregiving burden) as well as additional health problems should be considered when identifying persons with stagnating pain courses.

Fear of Movement in People with CRPS: A Psychometric Evaluation of the Tampa Scale-11 for Kinesiophobia.

People with complex regional pain syndrome (CRPS) commonly report a fear of movement that can worsen symptoms and increase disability. The Tampa Scale of Kinesiophobia (TSK) is used to evaluate fear of movement and (re)injury, but findings have been inconsistent in different populations. To evaluate the psychometric properties of the Persian version of TSK-11 in individuals with upper limb CRPS. Specifically, to determine if the factor structure aligns with the original two-factor model, consisting of "activity avoidance" and "somatic focus." People with CRPS (n=142, mean age=42, 54% female) completed the TSK. The psychometric testing included internal consistency and test-retest reliability (intra-class correlation coefficient), and convergent construct validity. Confirmatory and Exploratory factor analyses (CFA, EFA) were performed to evaluate the structural validity. The TSK-11 showed acceptable internal consistency (Cronbach alpha 0.93) and excellent test-retest reliability (ICC=0.93, 95% CI: 0.92 to 0.94). The Standard Error of Measurement and Minimal Detectable Change were 4.3 and 11.7, respectively. The results also demonstrated excellent criterion validity (r=0.81). CFA demonstrated that the original two-factor model did not fit. EFA derived a two-factor solution with different items. The factor structure accounted for 64.91% of the variance, and the internal consistency of the factors was acceptable (>0.90). Expert consensus suggested naming these two factors as Fear-avoidance, Magnification & Helplessness. The TSK-11 demonstrates excellent retest reliability in people with CRPS. The original two-factor structure was not confirmed, and a new 2-factor structure of the TSK-11 proposed consisting of subscales for Fear Avoidance beliefs and Magnification/Helplessness. Given the overlap between these constructs and the construct of pain catastrophizing, further study is needed to clarify both measures' content validity and relative uniqueness.

Cross-cultural translation and psychometric validation of the French version of the Fear-Avoidance Components Scale (FACS).

The Fear-Avoidance Components Scale (FACS) is a reliable and valid instrument widely used to assess fear-avoidance beliefs related to pain and disability. However, there is a scarcity of validated translations of the FACS in different cultural and linguistic contexts, including the French population. This study aimed to translate and validate the French version of the FACS (FACS-Fr/CF), examining its psychometric properties among French-speaking individuals. A cross-cultural translation process-including forward translation, backward translation, expert committee review, and pre-testing-was conducted to develop the FACS-Fr/CF. The translated version was administered to a sample of French-speaking adults (n = 55) with chronic musculoskeletal pain. Internal consistency (including confirmatory analyses of the 2 factors identified in the Serbian version), test-retest reliability and convergent validity were then assessed. The FACS-Fr/CF demonstrated high global internal consistency (α = 0.94, 95% CI: 0.91-0.96) as well as high internal consistency of the 2 factors identified in the Serbian version (α = 0.90, 95% CI: 0.86-0.94 and α = 0.90, 95% CI: 0.85-0.94, respectively). Test-retest analysis revealed a moderate (close to high) reliability (ICC = 0.89; 95% CI: 0.82-0.94 and r = 0.89; p<0.005). Convergent validity was supported by significant correlations between the FACS-Fr/CF scores and the Tampa Scale for Kinesiophobia (r = 0.82; p < 0.005), the Pain Catastrophizing Scale (r = 0.72; p < 0.005) and the Hospital Anxiety and Depression Scale (r = 0.66; p < 0.005). The present study provides evidence for the cross-cultural translation and psychometric validation of the FACS-Fr/CF. The FACS-Fr/CF exhibits a high internal consistency, a moderate (close to high) test-retest reliability, and good construct validity, suggesting its utility in assessing fear-avoidance beliefs in the French-speaking population. This validated tool can enhance the assessment and understanding of fear-avoidance behaviors and facilitate cross-cultural research in pain-related studies.

Establishing the prognostic profile of patients with work-related musculoskeletal disorders: Development and acceptability of the MAPS questionnaire.

Work-related musculoskeletal disorders (WRMD) are the most common causes of disability worldwide and are associated with significant use of healthcare. One way to optimize the clinical outcomes of injured workers receiving rehabilitation is to identify and address individual prognostic factors (PF), which can facilitate the personalization of the treatment plan. As there is no pragmatic and systematic method to collect prognostic-related data, the purpose of the study was to develop and assess the acceptability of a set of questionnaires to establish the "prognostic profile" of workers with WRMD. We utilized a multistep process to inform the acceptability of the Measures Associated to PrognoStic (MAPS) questionnaire. During STEP-1, a preliminary version of the was developed through a literature search followed by an expert consensus including a patient-advisor. During STEP-2, future users (rehabilitation professionals, healthcare administrators and compensation officers) were consulted through an online survey and were asked to rate the relevance of each content item; items that obtained ≥80% of "totally agree" answers were included. They were also asked to prioritize PF according to their usefulness for clinical decision-making, as well as perceived efficacy to enhance the treatment plan. The questionnaire was developed with three categories: the outcome predicted, the unique PF, and prognostic tools. Personal PF (i.e.: coping strategies, fear-avoidance beliefs), pain related PF (i.e.: pain intensity/severity, duration of pain), and work-related PF (i.e.: work physical demands, work accommodations) were identified to be totally relevant and included in the questionnaire. 84% of the respondents agreed that their patients could complete the MAPS questionnaire in their clinical setting, while 75% totally agreed that the questionnaire is useful to personalize rehabilitation interventions. The MAPS questionnaire was deemed acceptable to establish the "prognostic profile" of injured workers and help the clinicians in the treatment decision-making process.

Effects of Isolated Myofascial Release Therapy in Patients with Chronic Low Back Pain-A Systematic Review.

Dysfunctions of the lumbosacral area and related pain syndromes, such as chronic low back pain (CLBP), are among the most common musculoskeletal problems in modern society. The purpose of this study was to evaluate the effectiveness of isolated myofascial release techniques (MFR) in the treatment of CLBP in adults. PubMed, Web of Science, Scopus, and Cochrane Library databases were searched for studies published from 1 January 2013 to 1 March 2023. We included English-language randomized controlled trials evaluating the effect of isolated MFR performed by a specialist on adults with CLBP. Only studies with a comparison group without treatment or with sham MFR were included. A total of 373 studies were detected, of which 6 studies were finally included in this review. There was a total of 397 CLBP patients aged 18-60 in all study groups. The studies evaluated the effects of a series of MFR treatments as well as a single intervention. After applying a series of treatments, a statistically significant reduction in pain intensity, improvement in the range of motion, reduction in the level of functional disability and fear-avoidance beliefs, as well as a decrease in the activity of paraspinal muscles at maximum trunk flexion were demonstrated. A single, 40-min complex intervention involving tissues at various depths significantly reduced the level of pain, improved the range of motion, and reduced the resting activity of paraspinal muscles in the standing position, but did not affect postural stability. The use of a single 5 min MFR technique did not affect pain intensity and sensitivity and functional disability. The findings suggest that the use of a series of isolated MFR improves the condition of patients with CLBP by reducing the intensity of pain, improving functional efficiency, and reducing the activity of the paraspinal muscles in the position of maximum forward bend. The use of a single intervention containing a set of techniques covering superficial and deep tissue also reduces the intensity of pain, improves mobility, and reduces the resting activity of the paraspinal muscles in a standing position. Given the small number of eligible studies with limitations, conclusions should be interpreted with caution and avoid overgeneralizing the benefits of isolated MFR based on limited or mixed evidence.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy.

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

The effect of patient-led goal setting approach combined with pain neuroscience education or manual therapy in patients with chronic low back pain: protocol for a parallel-group randomized controlled trial

BackgroundLow back pain (LBP) is a multifactorial disorder associated with a high range of physical and psychological burden on the society. Patient-led goal-setting approach has shown potential effects for improving chronic LBP. However, there are few studies investigating its benefits when combined with a supplementary intervention. This paper, therefore, presents a protocol for a randomized control trial (RCT) to study the effect of a patient-led goal-setting approach combined with pain neuroscience education (PNE) or manual therapy (MT) among patients with chronic LBP.MethodsA total of 105 patients suffering from chronic LBP will be recruited via flyers displayed in hospitals and universities, and those meeting the study’s criteria will randomly be allocated into a patient-led goal-setting approach with the PNE group, and/or with the MT program group, and/or a control group. The primary outcomes will be the pain intensity and disability. Secondary outcomes include quality of life, depression, anxiety and stress, fear avoidance beliefs, kinesophobia, pain self-efficacy, catastrophic pain, neurophysiology of pain, and central sensitivity. All the outcomes will be recorded at 2 months after receiving the treatment as post-test sessions and after 4 and 12 months as follow-up sessions. The Ethics Committee in Research at Sport Sciences Research Institute of Iran approved the protocol of this trial (IR.SSRC.REC.1400.084). Written, informed consent to participate will be obtained from all participants. All methods will be conducted in accordance with the ethical standards of the Declaration of Helsinki and in accordance with relevant guidelines and regulations. We will disseminate the findings through peer-reviewed publications and conference presentations and send them to the participants.DiscussionThis trial will demonstrate which supplementary intervention can better improve the impact of a patient-led goal-setting approach to treat LBP. If successful, the results will potentially have implications for athletic trainers, physiotherapists, and health care practitioners.Trial registrationIRCT Iranian Registry of Clinical Trials IRCT20210927052616N1. Registered on November 03, 2021.

Effect of Adding Diaphragmatic Breathing Exercises to Core Stabilization Exercises on Pain, Muscle Activity, Disability, and Sleep Quality in Patients With Chronic Low Back Pain: A Randomized Control Trial

ObjectiveThe purpose of this study was to test the effect of adding diaphragmatic breathing exercises (DBEs) to core stabilization exercises (CSEs) for patients with chronic low back pain (CLPB). MethodsTwenty-two patients with CLPB were randomly allocated to the experimental (DBE + CSE) or control group (CSE only). They were given 12 treatment sessions 3 times a week for 4 weeks. Patients were evaluated before and after the 12 sessions. Surface electromyography of transverse abdominis, Oswestry Disability Index, Fear Avoidance Belief Questionnaire, Pittsburgh Sleep Quality Index, Numeric Pain Rating Scale, and chest expansion were used as outcome measures for pain, muscle activity, disability, and sleep quality. ResultsThe outcome measure scores showed statistical significance of (P = .01) in time effect on muscle activity, sleep quality, disability score, pain score, fear-avoidance belief of patients and chest expansion; and group effect on Fear Avoidance Belief Questionnaire and physical activity parameter (P = .05). An interaction effect (time x group) on muscle activity for right transverse abdominus during tuck in (P = .01) and chest expansion (P = .01) was also found; however, no significant difference was found related to other parameters. ConclusionThe combination of DBE and CSE interventions compared to CSE alone showed improvement in the measured parameters for patients with CLBP. Incorporating DBE with CSE also improved muscle activation and chest expansion.

Changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy mediate changes in pain intensity on disability in the treatment of chronic low back pain.

Treatment of chronic low back pain (CLBP) based on the fear-avoidance model (FAM) has received support in randomized controlled trials, but few studies have examined treatment processes associated with treatment outcome. This study examined changes in pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy as mediators of the relation between changes in pain intensity and disability in exposure-based treatment of CLBP. Data from a randomized controlled trial with 2 treatment arms (exposure treatment based on the FAM with/without in-session exposure) was pooled, including only participants with complete data (N = 69). Change scores (pre to booster session) were computed for all variables, and the indirect effect of change in pain intensity on change in 3 measures of disability, through change in the proposed mediators, was tested in parallel mediation analyses. Decreases in pain catastrophizing and fear-avoidance beliefs, as well as increases in pain self-efficacy, mediated a unique proportion of the relation between changes in pain intensity and disability, depending on the outcome measure. The direct relation between changes in pain intensity and disability was absent when indirect effects were controlled. The results suggest that the way pain is interpreted (pain catastrophizing, fear-avoidance beliefs), as well as pain self-efficacy, are all more critical for reducing disability in exposure-based treatment of CLBP than symptom relief per se.

Additional effect of pain neuroscience education to spinal manipulative therapy on pain and disability for patients with chronic low back pain: a randomized controlled trial

BackgroundSpinal manipulative therapy (SMT) demonstrates small effects on pain intensity in low back pain. Combining SMT with a psychosocial intervention like pain neuroscience education (PNE) could promote additional effect. ObjectivesTo evaluate the additional effect of PNE when combined to SMT on pain intensity and low back pain-related disability in patients with chronic low back pain (CLBP). MethodOne hundred and four patients with CLBP of both sexes aged between 18 and 55 years were treated with PNE + SMT compared to SMT alone. The primary outcome measures were pain intensity and disability post-treatment (4 weeks). Secondary outcomes were fear-avoidance beliefs, global perceived effect of improvement, and pain self-efficacy. Results were obtained immediately post-treatment and at three follow-ups (30-days, 90-days, and 180-days). ResultsNo significant between-group difference was observed for pain intensity and disability post-treatment. In contrast, our results showed a significantly longer additional effect for the group treated with SMT + PNE for the following outcomes: pain intensity (change baseline to 90 day follow-up = −0.90 [95% CI= −1.76, −0.4] and change baseline to 180 day follow-up = −1.19 [95% CI= −2.06, −0.32]) and low back pain-related disability, global perceived effect of improvement and pain self-efficacy (180th day follow-up). ConclusionThe results of this trial suggest the addition of PNE to SMT did not bring any additional effect on pain intensity and disability in the short term, but SMT + PNE can result in longer-lasting effects in patients with CLBP and that such an effect could be related to a possible mediator effect of pain self-efficacy.

Effect of an Online Cognitive-Motor Control Training Program on Pain and Its Related Psychological Factors in People With Non-Specific Chronic Low Back Pain: A Randomized Clinical Trial

Background and Aims Non-specific chronic low back pain (LBP) is one of the most common types of LBPs. Due to the complexity of the injury mechanism in this condition, combined interventions and treatments have been suggested. People’s attitudes towards pain and the interaction between biological characteristics of people and social/psychological factors should be considered. Due to the high cost of face-to-face therapy and the difficulty of access to subjects, recent studies have used online methods. So far, the effectiveness of online interventions in the treatment of chronic LBP has not been studied. Therefore, this study aims to investigate the effect of an online cognitive-motor control training program on pain and its related psychological factors in people with non-specific chronic LBP. Methods This is a randomized clinical trial conducted on 44 female and male patients with non-specific chronic LBP aged 25-55 years, selected from the physiotherapy clinics in Tehran and Karaj provinces of Iran based on the inclusion and exclusion criteria, and randomly divided into two groups of 22 including training and control. The intervention was provided at 18 sessions for 12 weeks. Pain and its related psychological factors were assessed by the visual analog scale, fear-avoidance belief questionnaire, and pain self-efficacy questionnaire. For statistical analysis, repeated measures analysis of variance, independent t-test, and paired t-test were used. The significance level was set at 0.05. Results There was a significant difference between the pre-test and post-test scores of the training group in pain, pain self-efficacy, avoidance of physical activity, and avoidance of work (P&lt;0.001). In the control group, no significant difference was reported in these variables between the pre-test and post-test scores. Conclusion The online cognitive-motor control training program can relieve pain and improve the pain-related psychological factors of people with non-specific chronic LBP. It can be used for this purpose in these people.

A Pilot Study for Effectiveness of Non-Pharmacological versus Pharmacological Treatment Strategies for Lumbar Disc Herniation: A Pragmatic Randomized Controlled Trial.

We aimed to compare the efficacy, safety, and cost-effectiveness of non-pharmacological- and pharmacological treatment strategies for Lumbar disc herniation (LDH) in pragmatic clinical settings. This study was a pilot, two-armed, parallel pragmatic randomized controlled trial. Thirty patients aged 19-70 years with a numeric rating scale (NRS) score ≥5 for sciatica and confirmed LDH on magnetic resonance imaging (MRI) were included. Participants were assigned in a 1:1 ratio to non-pharmacological (non-Phm) or pharmacological (Phm) treatment group. They were treated for 8 weeks and a total follow-up period was 26 weeks after randomization. Non-Phm treatment included acupuncture, spinal manual therapy, etc., Phm included medication, injection, nerve block, etc., The primary outcome was a numeric rating scale (NRS) of radiating leg pain. NRS for low back pain, Oswestry disability index, visual analog scale, Fear-Avoidance Beliefs Questionnaire, patient global impression of change, Short Form-12 Health Survey, version 2, 5-level European Quality of Life-5 dimensions (EQ-5D) were also measured. Linear mixed model was used to evaluated the difference in change of outcomes from baseline between two groups. An economic evaluation was conducted using incremental cost-effectiveness ratios. There was no significant difference between the two groups in the intervention period, but non-Phm group showed significantly greater degree of improvement in follow-up of Week 14. Difference in the NRS for sciatica and ODI were 1.65 (95% CI 0.59 to 2.71, p=0.003) and 8.67 (95% CI 1.37 to 15.98, p=0.21), respectively in Week 14. The quality-adjusted life year (QALY) value calculated by EQ-5D and Short Form-6 Dimension were 0.006 (95% CI -0.012 to 0.024, p=0.472) and 0.015 (95% CI -0.008 to 0.038, p=0.195) higher in non-Phm group than in Phm group. The cost was lower in non-Phm group than in Phm group (Difference: -682, 95% CI -3349 to 1699, p=0.563). We confirmed that the non-Phm treatment could be more cost-effective treatments than Phm treatments and feasibility of a large-scale of main study in future.

Immediate effect of passive hamstring stretching on flexibility and relationship with psychosocial factors in people with chronic low back pain

BackgroundHamstring muscle tightness contributes to disability in people with chronic low back pain (CLBP). HM stretching improves flexibility in healthy individuals, but the immediate effect of stretching is unknown in people with CLBP. Moreover, the stretching effect could be influenced by psychosocial factors. ObjectivesTo evaluate the immediate effect of passive HM stretching on flexibility in people with CLBP and the relationships between psychosocial factors and change in hamstring flexibility. DesignNon-randomized, pilot trial. MethodOne minute of passive stretching was performed in 90 people with CLBP. Change in Active Knee Extension and Straight Leg Raise angles (digital inclinometer), and Fingertips-to-Floor distance (measuring tape) were measured before and immediately after stretching. Correlations between change in flexibility and baseline Fear-Avoidance Beliefs Questionnaire (FABQ) and Hospital Anxiety and Depression Scale (HADS) scores were analyzed. ResultsHamstring flexibility improved significantly after stretching; Active Knee Extension mean difference was 4° (95% CI, 2.4 to 5.1; p < 0.001, right ES = 0.24, left ES = 0.23); Straight Leg Raise mean difference was 7° (95% CI, 5.5 to 8.6, p < 0.001, right ES = 0.44, left ES = 0.42), Fingertips-to-Floor mean difference was 2 cm (95% CI, 1.7 to 3.0, p < 0.001, ES = 0.20). No correlation was found between improvement in any of the hamstring flexibility measurements and FABQ or HADS scores (p > 0.05). ConclusionsPassive hamstring stretching induced an immediate, statistically significantly improvement in hamstring flexibility, but only the change in Straight Leg Raise amplitude was clinically important. Psychosocial factors were not related to improvements in flexibility after hamstring stretching.