Réseau de prise en charge de la lombalgie chronique

ObjectifsIls sont d’étudier l’efficience d’un réseau de santé de maintien dans l’emploi pour les patients lombalgiques chroniques, d’appréhender la réalisation des aménagements du poste de travail des lombalgiques ayant une inadéquation santé/travail et également d’apprécier la communication interprofessionnelle entre le médecin du travail et les autres intervenants du réseau. Méthodes Étude descriptive et rétrospective, réalisée par questionnaires envoyés aux 53 médecins du travail de 88 patients inclus dans le réseau Lombaction. Étaient inclus dans l’étude tous les lombalgiques chroniques adressés initialement à la consultation pluridisciplinaire du réseau par leur médecin du travail, leur médecin traitant ou leur médecin rééducateur, et ayant ensuite bénéficié d’un programme de réentraînement à l’effort dans le cadre du réseau en 2006. Résultats Soixante cinq questionnaires ont été remplis par 43 médecins du travail (soit 73,9 % de réponses). Les indicateurs de santé au travail montrent le caractère handicapant des lombalgies présentées par les patients. Le maintien dans l’emploi est majoritairement obtenu grâce soit à une amélioration clinique liée au programme Lombaction de réentraînement à l’effort, soit à un aménagement du poste de travail ou à la combinaison des deux. Une intervention ergonomique, afin de contribuer à l’effort de maintien dans l’emploi, est vivement souhaitée par les médecins du travail. Toutefois le réseau Lombaction souffre d’un manque de communication entre les différents intervenants, qui nuit à l’interdisciplinarité requise à tout réseau de santé. Conclusion La prise en charge des lombalgiques chroniques par le réseau Lombaction se doit d’être interdisciplinaire au-delà de la consultation pluridisciplinaire d’inclusion. Cela nécessite du temps et une confiance partagée entre les différents acteurs de ce réseau de santé. L’information au sein du réseau promue par le coordinateur du réseau, en particulier sur les missions de chacun des intervenants, doit contribuer à décloisonner le programme Lombaction et à parfaire l’interdisciplinarité au profit des patients

Effectiveness of three treatment strategies on occupational limitations and quality of life for patients with non-specific chronic low back pain: Is a multidisciplinary approach the key feature to success: study protocol for a randomized controlled trial

BACKGROUND: Chronic low back pain (cLBP) is a significant public health problem, being the primary cause of work absenteeism, as well as affecting sufferers\u27 quality of life, in industrialized society. International guidelines recommend intensive multidisciplinary approaches for patients with cLBP. However, these costly and time-consuming programs can only be offered to a minority of the most heavily affected patients and therefore do not seem likely to respond to public health requirements. Lighter programs may be an alternative to full time hospital-based programs with valuable results in terms of disability and occupational activity for cLBP patients. It is therefore important to define both what the determining components of management to improve activity restriction are and how to treat a larger number of patients more effectively at a lower cost. The aim of this study is to compare three programs with various levels of intensity and multidisciplinary. METHODS/DESIGN: This paper describes the protocol for a prospective, randomized, controlled, clinical trial in working aged patients with cLBP. Three treatment strategies are compared: (1) intensive and multidisciplinary program conducted in a rehabilitation center; (2) less intensive outpatient program conducted by a private physiotherapist; (3) mixed strategy combining the same out program with a multidisciplinary intervention. The primary outcome of the trial is the impact of the mixed strategy on being able to work compared to hospital centered-program and out program. The secondary outcome is the impact of the mixed strategy on quality of life and social ability compared to the two others programs. The intervention part of the trial programs will take 5 weeks and observational follow-up will take 12 months. The sample size will be 180 participants (60 for each arm). The project has been approved by the Ethical Committee of Angers Hospital, France. DISCUSSION: On the hypothesis that a multidisciplinary approach is the key feature to programs success in reducing social and occupational impairment in cLBP patients, we suggest that it is possible to achieve the same results with less intensive strategies if a multidisciplinary approach is maintained. TRIAL REGISTRATION: Current Controlled Trials NCT02030171

Multidisciplinary intensive functional restoration versus outpatient active physiotherapy in chronic low back pain: a randomized controlled trial.

STUDY DESIGN: Randomized parallel group comparative trial with a 1-year follow-up period. OBJECTIVE: To compare in a population of patients with chronic low back pain, the effectiveness of a functional restoration program (FRP), including intensive physical training and a multidisciplinary approach, with an outpatient active physiotherapy program at 1-year follow-up. SUMMARY OF BACKGROUND DATA: Controlled studies conducted in the United States and in Northern Europe showed a benefit of FRPs, especially on return to work. Randomized studies have compared these programs with standard care. A previously reported study presented the effectiveness at 6 months of both functional restoration and active physiotherapy, with a significantly greater reduction of sick-leave days for functional restoration. METHODS: A total of 132 patients with low back pain were randomized to either FRP (68 patients) or active individual therapy (64 patients). One patient did not complete the FRP; 19 patients were lost to follow-up (4 in the FRP group and 15 in the active individual treatment group). The number of sick-leave days in 2 years before the program was similar in both groups (180 ± 135.1 days in active individual treatment vs. 185 ± 149.8 days in FRP, P = 0.847). RESULTS: In both groups, at 1-year follow-up, intensity of pain, flexibility, trunk muscle endurance, Dallas daily activities and work and leisure scores, and number of sick-leave days were significantly improved compared with baseline. The number of sick-leave days was significantly lower in the FRP group. CONCLUSION: Both programs are efficient in reducing disability and sick-leave days. The FRP is significantly more effective in reducing sick-leave days. Further analysis is required to determine if this overweighs the difference in costs of both programs

Treatment Efficacy, Clinical Utility, and Cost-Effectiveness of Multidisciplinary Biopsychosocial Rehabilitation Treatments for Persistent Low Back Pain: A Systematic Review

Study Design: Systematic review. Objectives: To review the current literature on the treatment efficacy, clinical utility, and cost-effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from persistent (nonspecific) lower back pain (LBP) in relation to pain intensity, disability, health-related quality of life, and work ability/sick leave. Methods: We carried out a systematic search of Web of Science, Cochrane Library, PubMed Central, EMBASE, and PsycINFO for English- and German-language literature published between January 2010 and July 2017. Study selection consisted of exclusion and inclusion phases. After screening for duplication, studies were excluded on the basis of criteria covering study design, number of participants, language of publication, and provision of information about the intervention. All the remaining articles dealing with the efficacy, utility, or cost-effectiveness of intensive (more than 25 hours per week) MBR encompassing at least 3 health domains and cognitive behavioral therapy–based psychological education were included. Results: The search retrieved 1199 publications of which 1116 were duplicates or met the exclusion criteria. Seventy of the remaining 83 articles did not meet the inclusion criteria; thus 13 studies were reviewed. All studies reporting changes in pain intensity or disability over 12 months after MBR reported moderate effect sizes and/or p-values for both outcomes. The effects on health-related quality of life were mixed, but MBR substantially reduced costs. Overall MBR produced an enduring improvement in work ability despite controversy and variable results. Conclusions: MBR is an effective treatment for nonspecific LBP, but there is room for improvement in cost-effectiveness and impact on sick leave, where the evidence was less compelling

Occupational advice for Patients undergoing Arthroplasty of the Lower limb: An intervention development and feasibility study (The OPAL Study)

Background Hip and knee replacements are regularly performed for patients who work. There is little evidence about these patients’ needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. Objective(s) To develop an occupational advice intervention to support early recovery to usual activities including work which is tailored to the requirements of patients undergoing hip and knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks Design An intervention mapping (IM) approach was used to develop the intervention. The research methods employed were: rapid evidence synthesis; qualitative interviews with patients and stakeholders; prospective cohort study; survey of clinical practice; modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the IM process. Setting Orthopaedic departments within NHS secondary care. Participants Patients in work, and intending to return to work following primary elective hip and knee replacement surgery; healthcare professionals and employers. Interventions Occupational advice intervention. Main outcome measures Development of an occupational advice intervention. Fidelity of the developed intervention when delivered in a clinical setting. Patient and clinician perspectives of the intervention. Preliminary assessments of intervention effectiveness and cost. Results A cohort study (154 patients), 110 stakeholder interviews, survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, personalized return to work plan and co-ordination from the healthcare team to support the delivery of 13 patient and 20 staff performance objectives (POs). To support delivery, a range of tools (e.g. occupational checklists, patient workbooks, employer information), roles (e.g. return-to-work coordinator) and training resources were created. Feasibility was assessed in 21 of the 26 patients recruited from 3 NHS trusts. Adherence with the defined performance objectives was 75% for patient POs and 74% for staff POs. The intervention was generally well received although the short timeframe available for implementation and concurrent research evaluation led to some confusion amongst patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. Limitations Implementation and uptake of the intervention was not standardized and was limited by the study timeframe. Evaluation of the intervention involved a small number of patients which limited the ability to assess it. Conclusions The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention Future work The intervention warrants a randomised controlled trial to assess its clinical and cost effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure adoption is sustained. Funding This project was funded by the NIHR Health Technology Assessment programme (project number 15/28/02) Trial Registrations International Standard Randomised Controlled Trials Number Trial ID: ISRCTN27426982 International prospective register of systematic reviews (PROSPERO) Registration: CRD4201604523

Comparison of Functional Restoration with 3 hours per week Physical Therapy in Chronic Low Back Pain at two years follow-up

International audienceIntroduction: Functional restoration programs (FRP) are recommended in chronic low back pain, but are only available or a limited number of patients. An ambulatory active individual therapy (AIT) could be an easier option. Aim: A prospective randomized controlled study to compare the medium-term outcomes of an AIT with those of a FRP. Patients and methods: One hundred thirty-two adults were treated during five weeks, either in a FRP (150 hours in a rehabilitation centre) or in an AIT (15 hours supervised by private practice physiotherapists). Evaluation criteria were trunk flexibility, back flexor and extensor endurance (Ito and Sorensen tests), general endurance, pain intensity, Dallas Pain Questionnaire (DPQ) scores (on daily activities (DA), anxiety depression, social interest, and work and leisure activities(WL)), and the number of days of sick leave. Results: Fifty-one percent of patients were on sick leave before treatment (mean duration, 180 days in the 2 years before treatment). All outcome measures improved after treatment, except endurance in AIT. At two years follow-up, 15 patients (11.3%) were lost to follow up; all physical criteria (except endurance) were better than before treatment without difference between groups; pain intensity was improved only in FRP; DPQ scores were improved only on DA and WL, with better results on WL in FRP. The number of days of sick leave in the two years after treatment was significantly improved, with no difference between groups (73.5 days in AIT versus 53.5 in FRP, p=0.45). Conclusions: AIT shows good results and could be sufficient for a large proportion of patients, but further studies are necessary to precise orientation criteria between the two therapies

Efficiency of three treatment strategies on occupational and quality of life impairments for chronic low back pain patients is the multidisciplinary approach the key feature to success?

International audienceObjective - To compare the effectiveness of three treatment strategies for chronic low back pain with varying biomechanical intensity and multidisciplinary approach. Methods - A monocentric randomized controlled trial with a 12-months follow-up, conducted in the French Valley Loire region from May 2009 to April 2013. Participants were working-aged patients with chronic low back pain referred to a French chronic low back pain care-network to support medical and occupational issues. Three treatment strategies, each for five weeks were compared: (i) intensive and multidisciplinary program conducted in a rehabilitation center; (ii) less intensive outpatient program conducted by a trained private physiotherapist; (iii) mixed strategy combining the same outpatient program associated with a weekly multidisciplinary intervention. The effects of treatment conditions were compared using an "intention to treat" approach: Number of days' sick leave during the 12-months following treatment, and quality of life and social ability assessed by auto-questionnaires. Results - A total of 159 patients (58.9% men, 41.5 ± 10.3 years old, median duration of sick leave = 221.0 days (127.5-319.0)) were included. Sick leave duration significantly decreased during the 12-months following treatment in the three groups. There was no significant difference for the evolution of participants' quality of life, social ability, and personal beliefs between the three groups. Conclusion - This study confirms that disparate treatments might show similar effectiveness because they could all work through concomitant changes in beliefs, attitudes, and coping mechanisms. The original mixed strategy can treat a larger number of chronic low back pain patients, at a lower cost and provide local community-based care. Clinical trial registration - NCT02030171