Reductions in movement-associated fear are dependent upon graded exposure in chronic low back pain : an exploratory analysis of a modified 3-item fear hierarchy

Objective: To explore the effectiveness of a modified fear hierarchy on measuring improvements in movement-associated fear in chronic low back pain. Methods: A modified 3-item fear hierarchy was created and implemented based on principles of graded exposure. This study was an exploratory analysis of the modified 3-item fear hierarchy from a larger clinical trial data set. Both groups received pain education and exercise, either bodyweight or strength training. Both groups performed item one on the hierarchy, the squat. Only the strength training group performed item 2, the deadlift. Neither group performed item 3, the overhead press. Analysis of Covariance and stepwise linear regression were used to explore results. Results: Improvement in movement-associated fear was conditional upon graded exposure. Both groups improved in the squat movement (p ≤ 0.05), which both performed. Only the strength training group improved in the deadlift (p ≤ 0.01), and neither improved in the overhead press (p ≥ 0.05). Conclusion: Reductions in movement-associated fear are conditional upon graded exposure, based on the use of a novel modified 3-item fear hierarchy. Further research is needed to understand the utility of this tool in a patient-led approach to co-designing a graded exposure-based intervention

Education improves decision-making of exercise physiologists regarding low back pain

Background: To investigate the efficacy of targeted education on clinical decision-making in accredited exercise physiologists. Methods: Fifty accredited exercise physiologists undertook a 4-hour targeted education session aimed to demonstrate why the biopsychosocial model is better suited to the management of chronic low back pain than the biomedical model. The pain attitudes and beliefs scale for physiotherapists and patient vignettes were collected before and after the targeted education to observe changes in beliefs and clinical decision-making. Results: A significant reduction in biomedical beliefs (P < 0.01) with no concomitant change in biopsychosocial beliefs was observed following the targeted education. Clinical decision-making significantly altered on all 8 items associated with the patient vignettes following the targeted education. Conclusion: Following targeted education, a reduction in biomedical beliefs with no concomitant change to biopsychosocial beliefs significantly altered clinical decision-making. The findings of this study support existing literature and demonstrate changes in attitudes and beliefs following education impact clinical decision-making in accredited exercise physiologists. Education interventions should focus on informing practitioners of the benefits of the biopsychosocial model as compared to the biomedical model for management of chronic low back pain rather than simply teaching biopsychosocial theory and application

The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain

Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear

Does a powerlifting inspired exercise programme better compliment pain education compared to bodyweight exercise for people with chronic low back pain? : a multicentre, single-blind, randomised controlled trial

Background: Contemporary management of chronic low back pain involves combined exercise and pain education. Currently, there is a gap in the literature for whether any exercise mode better pairs with pain education. The purpose of this study was to compare general callisthenic exercise with a powerlifting style programme, both paired with consistent pain education, for chronic low back pain. We hypothesised powerlifting style training may better compliment the messages of pain education. Methods: An 8-week single-blind randomised controlled trial was conducted comparing bodyweight exercise (n = 32) with powerlifting (n = 32) paired with the same education, for people with chronic low back pain. Exercise sessions were one-on-one and lasted 60-min, with the last 5–15 min comprising pain education. Pain, disability, fear, catastrophizing, self-efficacy, anxiety, and depression were measured at baseline, 8-weeks, 3-months, and 6-months. Results: No significant between-group differences were observed for pain (p≥0.40), or disability (p≥0.45) at any time-point. Within-group differences were significantly improved for pain (p≤0.04) and disability (p ≤0.04) at all time-points for both groups, except 6-month disability in the bodyweight group (p = 0.1). Behavioural measures explained 39–60% of the variance in changes in pain and disability at each time-point, with fear and self-efficacy emerging as significant in these models (p≤0.001) Conclusions: Both powerlifting and bodyweight exercise were safe and beneficial when paired with pain education for chronic low back pain, with reductions in pain and disability associated with improved fear and self-efficacy. This study provides opportunity for practitioners to no longer be constrained by systematic approaches to chronic low back pain

The moderating effect of treatment engagement on fear-avoidance beliefs in people with chronic low back pain

Objectives: The fear-avoidance model (FAM) is used to explain pain-related disability and design targeted interventions for people with chronic low back pain. While treatment engagement is critical, it is unknown how treatment moderates the FAM. Methods: This study examined whether pathways within the FAM were moderated by treatment engagement in 508 people with chronic low back pain. Measures of disability, pain, fear, catastrophizing, anxiety, depression, and self-efficacy were collected through self-report, and descriptors of treatment engaged within the last month (physical activity type, medication, allied and medical health practitioner). Moderated mediation analyses were performed to examine the conditional effect of treatment engagement on fear-avoidance pathways. Results: The conditional effect of anxiety on disability was only significant for people who did not report any treatment engagement in the last month (B=1.03, 95% confidence interval: 0.53-1.53, P<0.001). The effect of depression increased for people reporting more different types of treatment in the last month (1 level of treatment increase, B= 0.27, 95% confidence interval: 0.05-0.50, P=0.019). Conversely, greater treatment engagement had a positive influence on the mediating effect of self-efficacy. That is, the effect of pain on efficacy reduced with greater treatment engagement, with a concomitant increased effect of self-efficacy on disability. Discussion: Clinicians should explore the history and rationale behind patient treatment seeking behavior to ensure this is not reinforcing the negative effects of depressive symptoms on pain-related disability