Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review.

BACKGROUND AND OBJECTIVE: Recent systematic reviews show promising effects for multidisciplinary biopsychosocial (BPS) interventions in patients with chronic low back pain (CLBP). Nowadays, BPS interventions have also been developed for primary care physiotherapy settings. Our aim was to systematically review the evidence on the effectiveness of primary care BPS interventions in improving functional disability, pain, and work status for patients with CLBP. Secondly, we aimed to provide an elaborated overview of BPS intervention designs, physiotherapist training programs, and process-related factors (practical implementation). METHODS: We searched in scientific databases and reference lists. Randomized controlled trials (RCTs) evaluating primary care physiotherapist-led BPS interventions in adults (≥18 years) with nonspecific CLBP (≥12 weeks) were included. RESULTS: Our search resulted in 943 references; 7 RCTs were included (1,426 participants). Results show moderate-quality evidence (3 trials; 991 participants) that a BPS intervention is more effective than education/advice for reducing disability and pain in the short, medium, and long term. Low-quality evidence (4 trials; 435 participants) was found for no difference with physical activity treatments. CONCLUSIONS: BPS interventions seem more effective than education/advice and were found to be as effective as physical activity interventions in patients with CLBP. BPS interventions with a clear focus on psychosocial factors (understanding pain, unhelpful thoughts, coping styles, and goal setting) seem most promising. Sufficient delivery of BPS elements is expected when physiotherapists participate in training programs with extensive support prior and during delivery (manual, supervision, and informative resources).

The effect of threat information on acquisition, extinction, and reinstatement of experimentally conditioned fear of movement-related pain.

OBJECTIVE: The experiential acquisition of pain-related fear has been demonstrated by pairing a painful electrocutaneous stimulus pain-US; unconditioned pain stimulus) with one movement (CS+; conditioned stimulus) but not with another (CS-). However, it is expected that during acquisition through direct experience, pain-related fear can be intensified or weakened by verbally/visually transmitted information about the pain and its meaning. METHOD: Participants received threatening information (US-inflation), safety information (US-deflation), or no information about the pain-US (US-same). Additionally, we measured return of fear after a reinstatement procedure: two unsignaled pain-USs were presented in the experimental groups, but not in the control groups. RESULTS: We replicated the acquisition and extinction of experimentally induced fear of movement-related pain in healthy subjects both in the verbal reports and the eye-blink startle measures. Two reinstating pain-US presentations led to a differential return of self-reported fear and a nondifferential return of fear in the eye-blink startle responses. Although, we failed to find an effect of verbal/visual information regarding the meaning of the pain-US on the acquisition, extinction, or reinstatement of pain-related fear, we did observe a pain sensitization effect over time suggesting that our threat manipulation induced an increase of perceived threat in all groups. CONCLUSION: The results suggest that our threat manipulation might not have worked or that it was not sensitive enough to yield group-specific effects. We replicated acquisition, extinction, and return of experimentally conditioned fear of movement-related pain, but the threat manipulation failed to generate any additional effects.

Application of the enabling occupation II guidelines in a non-Canadian context.

BACKGROUND: The Canadian Enabling Occupation II guidelines contain theory and examples of how to apply client-centredness in occupation-based practice. Little information is available about the feasibility of the guidelines in other contexts. For 18 months, nine Dutch occupational therapists participated in a community of practice to explore, together with three researchers, their experiences with the application of the Enabling Occupation II guidelines. PURPOSE: To understand the experiences of Dutch occupational therapists with the application of the Enabling Occupation II guidelines. METHOD: A qualitative study using four focus group discussions and content analysis. FINDINGS: Four themes emerged: (1) an indication that the guidelines of Enabling Occupation II are in line with values and norms of Dutch occupational therapists, (2) the meaningfulness of an intensive process of studying, discussing, applying and reflecting, (3) the struggles faced by the occupational therapists with translating English and getting a grip on concepts and (4) the challenges to implementing the guidelines in practice. IMPLICATIONS: Findings indicate that Enabling Occupation II embody values and norms of Dutch occupational therapists. They experience many benefits in their doing, thinking and being when applying the guidelines in practice. Struggles with reading English, getting a grip on concepts and theories, and difficulties in handling obstacles indicate that the application of the guidelines takes effort. An understanding of the philosophy, application, and reflection on professional identity may be prerequisites for appraising the feasibility of adoption of client-centred guidelines cross-culturally.