Graded Activity for Older Adults with Chronic Low Back Pain: Program Development and Mixed Methods Feasibility Cohort Study.

BACKGROUND: Persistent pain is highly prevalent in older adults and can lead to functional limitations in activities of daily living, and to psychosocial distress. There is a lack of established active therapy programs, especially for older adults with chronic pain. OBJECTIVES: To develop a graded activity program and to evaluate its feasibility within a pilot study. DESIGN: Phase I/phase II trial of a complex intervention. A mixed methods design was chosen to evaluate the feasibility, acceptability, and preliminary evidence of effectiveness. SUBJECTS AND SETTING: Several experts participated in the program development. Sixteen community-dwelling older adults (73.9 ± 5.9 years on average) with chronic low back pain and three primary care physical therapists attempted the program. METHODS: Guided semi-structured interviews were conducted with all patients and therapists and used a content-analytic approach. Measurements of self-rated functional status (HFAQ), average pain (NRS), falls self-efficacy (FES-I), and catastrophizing and avoidance beliefs (CAS-D 65+) were applied at baseline and after the intervention. RESULTS: The interviews revealed high acceptance, satisfaction, and practicality. Besides improvements in function and pain, patients mentioned more positive attitudes towards pain, activity, and self-confidence. There was a clinically relevant increase in physical function by 20.3%, a decrease in pain intensity, and a reduction in catastrophizing and avoidance behavior. CONCLUSION: This graded activity program demonstrated feasibility and high acceptance in aged individuals and therapists. Future studies with larger samples must confirm effectiveness. The principles also appear applicable to other chronic pain conditions. The program could easily be implemented in routine primary care.

[Acute pain management in paediatrics and geriatrics - pain assessment: which scale for which patient?]. / Akutschmerztherapie in Pädiatrie und Geriatrie - Schmerzmessung: Welche Schmerzskala bei welchen Patienten?

In the perioperative period acute pain is measured by one-dimensional scales concentrating on pain intensity. As part of a quality assurance procedure pain assessment is to be exercised during periods of rest and activity. Pain is a subjective experience. That is why self-report is the golden standard of pain assessment. Only in case self-report is not available due to mental development or to cognitive restraints, it has to be replaced by behavioural observation. Established scales are the visual analogue scale (VAS), the verbal rating scale (VRS), and the numerical rating scale (NRS) with a preference for the NRS. Scales that measure pain in children are the Faces-Pain-Scale and behavioural observation scales. The assessment of non verbal adults also has to rely on behavioural observation.

[Therapy of pain in multiborbid elderly patients]. / Schmerztherapie bei multimorbiden und betagten Patienten.

All human organ systems are prone to age-related physiological changes. Functional impairment is especially found in the liver, the kidneys, the nervous system, the gastrointestinal tract and the blood vessels. Changes in metabolism cause, e.g., changes in the composition of blood, reduction in neurotransmitters and the respective receptors, changes in calcium homeostasis with consequences for the stability of bones. As with any pharmacotherapy, the treatment of pain must consider these age-related factors. Adequate pain treatment is especially important in elderly patients, because the number of morbidities increases together with the number of pain conditions of different origin. In Germany, most patients with severe pain are undertreated. Although tumor pain, e.g., can be relieved in up to 95% of patients, up to 40% of patients under medical treatment still have pain, the German Pain League states. The WHO's pain ladder, developed in the 1980ies, is still regarded as an appropriate guideline, albeit too often disregarded by physicians, reflecting the reserve of patients and doctors towards opioids. With progress in opioid therapy, however, experts tend to early prescription of step-III-analgesics without sticking to the steps of the WHO ladder. Constipation, the major side effect of opioids, can be overcome by co-medication with laxatives. The combination of slow-release oxycodone with naloxone, an orally given antagonist of intestinal micro-receptors is effective as analgesic and maintains the normal bowel function.

TTM-based motivational counselling does not increase physical activity of low back pain patients in a primary care setting--A cluster-randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of a TTM-based motivational counselling approach by trained practice nurses to promote physical activity of low back pain patients in a German primary care setting. METHODS: Data were collected in a cluster-randomized controlled trial with three study arms via questionnaires and patient interviews at baseline and after 6 and 12 months. We analysed total physical activity and self-efficacy by using random effect models to allow for clustering. RESULTS: A total of 1378 low back pain patients, many with acute symptoms, were included in the study. Nearly 40% of all patients reported sufficient physical activity at baseline. While there were significant improvements in patients' physical activity behaviour in all study arms, there was no evidence for an intervention effect. CONCLUSION: The outcome may be explained by insufficient performance of the practice nurses, implementation barriers caused by the German health care system and the heterogenous sample. PRACTICE IMPLICATIONS: Given the objective to incorporate practice nurses into patient education, there is a need for a better basic training of the nurses and for a change towards an organizational structure that facilitates patient-nurse communication. Counselling for low back pain patients has to consider more specificated aims for different subgroups.

TTM-based counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain--a randomised controlled trial.

AIMS: The present study examines the outcome of counselling in physiotherapy based on the Transtheoretical Model (TTM) in a sample of elderly individuals with chronic low back pain. METHODS: In a prospective randomised trial with concealed assignment, elderly individuals with chronic low back pain were allocated to two treatment conditions. Both contained 10 sessions of physiotherapy, each of 20min duration. In addition, the experimental group (EG) received 10min counselling prior to every session based on the TTM, also provided by the physiotherapist, and the control group (CG) underwent a placebo ultrasound treatment with an inactivated device to control for the additional attention given to the EG. Assessments took place prior to the treatment (t1), immediately after termination of the treatment (t2), and at a 6-months follow-up. Outcome measures were physical activity calculated from one-week activity diaries, self-reported functional capacity, and range of motion measured by ultrasound topometry. RESULTS: A total of 170 individuals (64% female) with a mean age of 70.3 years (SD=4.4, range 65-84) participated in the study. The retention rate was 90%. At t3, both EG and CG showed increased physical activity and functional capacity, but no change in range of motion. Effect sizes were large. Contrary to our hypothesis, however, motivational training did not result in a better outcome compared with placebo treatment. CONCLUSION: The study does not provide evidence that a short TTM-based motivation programme is superior to placebo treatment regarding adherence to activity recommendations.

Binge drinking and health behavior in medical students.

OBJECTIVES: The objective of this study was to assess the prevalence of binge drinking and its relation to other health behaviors, drinking-related attitudes and perceived social norms among German medical students. METHODS: 271 first-year German medical students completed a cross-sectional, self-administered survey. A total of 252 (62% female and 38% male) students provided useable surveys. The mean age was 20.6years (S.D.=1.7). RESULTS: Most students reported heavy drinking with 24% having one episode in the past 2 weeks (Infrequent Bingers) and 28% having two or more episodes (Frequent Bingers). Men were more likely than women to have had a binge drinking episode. Frequent binge drinkers saw more pros of drinking and reported a higher temptation to drink than students in the other groups. Additionally, they were more likely to smoke, use cannabis, not exercise and not eat fruits and vegetables. All students overestimated their peers' alcohol intake and binge drinking frequency. CONCLUSIONS: Binge drinking was highly prevalent in this sample and clearly related to other health risk behaviors. Drinking rates were similar to college students in other Western countries. Future research needs to assess the consequences of this multiple risk behavior among medical students regarding academic and professional performance as well as personal health.

Use of complementary alternative medicine for low back pain consulting in general practice: a cohort study.

BACKGROUND: Although back pain is considered one of the most frequent reasons why patients seek complementary and alternative medical (CAM) therapies little is known on the extent patients are actually using CAM for back pain. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study embedded in a RCT. General practitioners (GPs) recruited consecutively adult patients presenting with LBP. Data on physical function, on subjective mood, and on utilization of health services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months RESULTS: A total of 691 (51%) respectively 928 (69%) out of 1,342 patients received one form of CAM depending on the definition. Local heat, massage, and spinal manipulation were the forms of CAM most commonly offered. Using CAM was associated with specialist care, chronic LBP and treatment in a rehabilitation facility. Receiving spinal manipulation, acupuncture or TENS was associated with consulting a GP providing these services. Apart from chronicity disease related factors like functional capacity or pain only showed weak or no association with receiving CAM. CONCLUSION: The frequent use of CAM for LBP demonstrates that CAM is popular in patients and doctors alike. The observed association with a treatment in a rehabilitation facility or with specialist consultations rather reflects professional preferences of the physicians than a clear medical indication. The observed dependence on providers and provider related services, as well as a significant proportion receiving CAM that did not meet the so far established selection criteria suggests some arbitrary use of CAM.

Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study.

BACKGROUND AND PURPOSE: Fear-avoidance beliefs in older adults with chronic low back pain (CLBP) can lead to disability. Graded exposure-based active physical therapy could be an option to enhance physical ability in older patients with CLBP. The purpose of this study was to develop a standardized graded exposure treatment according to the fear-avoidance model of musculoskeletal pain for older patients with CLBP and to examine its effectiveness and feasibility in the German health care system. METHODS: The study represents a phase I/phase II trial of a complex intervention. Taking a first step into the hierarchy of growing empirical evidence, a prospective 1-factor observational study was conducted with repeated measurements 1 week before and within 2 weeks after the intervention. Three physical therapists, who completed an introductory workshop, provided the treatment in the form of individual therapies. Sixteen participants 65 years or older with CLBP and perceived physical limitations were recruited. Four patient-reported outcome measures and semistructured interviews were conducted. The primary outcome was physical ability measured with the Hanover Functional Ability Questionnaire. Secondary outcomes were the numerical pain rating scale, and an age-specific and adapted 11-item short-form of the Patient Anxiety Symptom Scale, the KVS-D 65+, which quantified catastrophizing and avoidance beliefs. Fear of falling was measured with the Falls Efficacy Scale-International. For the analysis, Wilcoxon signed-rank test for paired samples and an α level of .05 were chosen. For the qualitative evaluation, semistructured interviews were conducted with the patients and physical therapists explored indicators of feasibility such as demands, acceptability, satisfaction, adaptation needs, and implementation. For content analysis, codes were primarily derived deductively and complemented by inductively derived new themes. RESULTS: A significant increase in physical ability after the treatment was observed with an effect size (ES) of 0.95 (P = .008). With regard to secondary outcomes, there was a statistically significant decrease in pain intensity (P = .029) and a reduction in catastrophizing (ES = 0.91; P = .021) and avoidance beliefs (ES = 1.37; P = .001). The interviews revealed good acceptance and satisfaction of the treatment by the patients and physical therapists. CONCLUSION: On the whole, the treatment appears effective and feasible. Apart from the benefits achieved by the participants, the study provides a basis for designing future studies at a higher level of evidence.

Determinants for receiving acupuncture for LBP and associated treatments: a prospective cohort study.

BACKGROUND: Acupuncture is a frequently used but controversial adjunct to the treatment of chronic low back pain (LBP). Acupuncture is now considered to be effective for chronic LBP and health care systems are pressured to make a decision whether or not acupuncture should be covered. It has been suggested that providing such services might reduce the use of other health care services. Therefore, we explored factors associated with acupuncture treatment for LBP and the relation of acupuncture with other health care services. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study. General practitioners (GPs) recruited consecutive adult patients with LBP. Data on physical function, subjective mood and utilization of health care services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months. RESULTS: A total of 179 (13 %) out of 1,345 patients received acupuncture treatment. The majority of those (59 %) had chronic LBP. Women and elderly patients were more likely to be given acupuncture. Additional determinants of acupuncture therapy were low functional capacity and chronicity of pain. Chronic (vs. acute) back pain OR 1.6 (CL 1.4-2.9) was the only significant disease-related factor associated with the treatment. The strongest predictors for receiving acupuncture were consultation with a GP who offers acupuncture OR 3.5 (CL 2.9-4.1) and consultation with a specialist OR 2.1 (CL 1.9-2.3). After adjustment for patient characteristics, acupuncture remained associated with higher consultation rates and an increased use of other health care services like physiotherapy. CONCLUSION: Receiving acupuncture for LBP depends mostly on the availability of the treatment. It is associated with increased use of other health services even after adjustment for patient characteristics. In our study, we found that receiving acupuncture does not offset the use of other health care resources. A significant proportion of patients who received did not meet the so far only known selection criterion (chonicity). Acupuncture therapy might be a reflection of helplessness in both patients and health care providers.

The Pain Beliefs and Perceptions Inventory: further evidence for a 4-factor structure.

This study employed the Pain Beliefs and Perceptions Inventory (PBPAI) (Williams and Thorn 1989) with a German sample (n = 193) of pain patients. The original version has 3 subscales: (1) self-blame (S-B), (2) perception of pain as mysterious (MYST), and (3) beliefs about the temporal stability of pain (TIME). Item statistics, factor structure, and discriminant validity are reported. Factor analysis favored a 4-factor structure and replicated a finding by Strong et al. (1992). The TIME scale can be subdivided into 2 subscales: beliefs that pain is a constant and enduring experience ("Constancy"), and beliefs about the long-term chronicity of pain ("Acceptance"). Constancy showed higher correlations with self-reported psychological symptomatology (anxiety, general physical troubles, pain intensity) than did Acceptance, MYST, and S-B.

Sex differences in cortisol response to noxious stress.

OBJECTIVES: Evidence has accumulated that men and women show different responses to noxious stimuli, with women exhibiting greater sensitivity to pain than men. Data concerning sex differences in cortisol response patterns have revealed inconsistent results so far. The purpose of the present study was to examine sex differences in subjective pain and cortisol response to a noxious stressor. METHODS: Seventy-six subjects (39 male and 37 female) were investigated by a modification of the cold pressor test that consisted of intermittent immersion of the hand into ice water (plunge test, PT). The PT was conducted twice, in consecutive trials, to guarantee a sufficient exposure to the noxious stressor for eliciting cortisol responses. In each trial, tolerance time and pain ratings visual analog scale (VAS) were assessed. Seven saliva samples (c1-c7) were collected to determine cortisol levels at baseline (c1-c2), directly before (c3) and 20 minutes after noxious stress (c4), and during recovery period (c5-c7). RESULTS: We found no significant sex differences in tolerance time in trial 1, but highly significant differences in tolerance time in trial 2, with higher tolerance times in men. No significant sex differences were found for the VAS ratings of pain intensity and unpleasantness in the 2 trials. In contrast, a significantly larger cortisol increase in men was observed compared with women. Analysis of covariance revealed that this result could not be attributed to sex differences in cortisol level at baseline and in tolerance time. DISCUSSION: The present study demonstrates that men show a larger cortisol response to a noxious stressor than women that is not attributable to sex differences in subjective pain. The conclusion of a causal relation between larger cortisol responses and higher pain tolerance thresholds in men is tempting but yet speculative.

The German multicenter, randomized, partially blinded, prospective trial of acupuncture for chronic low-back pain: a preliminary report on the rationale and design of the trial.

BACKGROUND: The efficacy of acupuncture treatment for chronic low-back pain has not been reliably proven because of a lack of good quality studies, leading to the necessity of developing the German Acupuncture Trial for Chronic Low-Back Pain (GERAC-cLBP) study. OBJECTIVE: The aim is to assess the effectiveness of traditional Chinese acupuncture for chronic low-back pain compared to sham acupuncture and with a conventional standard therapy. METHODS: This trial is a nationwide, multicenter, randomized, prospective, partially blinded study. The primary endpoint is the success rate after 6 months. Success is defined as an improvement of 33% or more of three pain-related items on the Van-Korff Pain Score or an improvement of 12% or more in the disability measured by the Hanover Functional Ability Questionnaire. Assessment of the effectiveness of the blinding of patients to the form of acupuncture they received will be conducted. All clinical endpoints are assessed centrally by blinded independent observers. The sample size, with a total of 1062 patients to be enrolled, is based on power calculations. Independent central randomization, data collection, data processing, and statistical analysis are provided. Success rates will be tested for differences using two-sided Fisher exact tests. In the primary analysis, all tests will be carried out on the basis of the intention-to-treat principle. Secondary analyses will be conducted according to protocol approaches. TRIAL STATUS: The pilot phase of the trial started in February 2002, the estimated duration of the study is 2.5 years. Enrollment is anticipated to be completed in the winter of 2003. CONCLUSION: The GERAC-cLBP study is currently the world's largest controlled trial of the effectiveness of acupuncture treatment for low-back pain. It will contribute to the evaluation of efficacy by means of evidence based medicine.

Low back pain patient subgroups in primary care: pain characteristics, psychosocial determinants, and health care utilization.

OBJECTIVES: In industrialized countries, low back pain (LBP) is one of the leading causes for prolonged sick leave, early retirement, and high health care costs. Providing the same treatments to all patients is neither effective nor feasible, and may impede patients' recovery. Recent studies have outlined the need for subgroup-specific treatment allocation. METHODS: This is a cross-sectional study that used baseline data from consecutively recruited patients participating in a guideline implementation trial regarding LBP in primary care. Classification variables were employment status, age, pain intensity, functional capacity (HFAQ), depression (CES-D), belief that activity causes pain (FABQ subscale), 2 scales of the SF-36 (general health, vitality), and days in pain per year. We performed k-means cluster analyses and split-half cross-validation. Subsequently, we investigated whether the resulting groups incurred different direct and indirect costs during a 6-month period before the index consultation. RESULTS: A 4-cluster solution showed good statistical quality criteria, even after split-half cross-validation. "Elderly patients adapted to pain" (cluster 1) and "younger patients with acute pain" (cluster 4) accounted for 55% of all patients. Cluster validation showed the lowest direct and indirect costs in these groups. About 72% of total costs per patient referred to clusters 2 and 3 ("patients with chronic severe pain with comorbid depression" and "younger patients with subacute pain and emotional distress"). DISCUSSION: Our study adds substantially to the knowledge of LBP-related case-mix in primary care. Information on differential health care needs may be inferred from our study, enabling decision makers to allocate resources more appropriately and to reduce costs.

Implementation of a guideline for low back pain management in primary care: a cost-effectiveness analysis.

STUDY DESIGN: Cost-effectiveness analysis alongside a cluster randomized controlled trial. OBJECTIVE: To study the cost-effectiveness of 2 low back pain guideline implementation (GI) strategies. SUMMARY OF BACKGROUND DATA: Several evidence-based guidelines on management of low back pain have been published. However, there is still no consensus on the effective implementation strategy. Especially studies on the economic impact of different implementation strategies are lacking. METHODS: This analysis was performed alongside a cluster randomized controlled trial on the effectiveness of 2 GI strategies (physician education alone [GI] or physician education in combination with motivational counseling [MC] by practice nurses)--both compared with the postal dissemination of the guideline (control group, C). Sociodemographic data, pain characteristics, and cost data were collected by interview at baseline and after 6 and 12 months. low back pain-related health care costs were valued for 2004 from the societal perspective. RESULTS: For the cost analysis, 1322 patients from 126 general practices were included. Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls. In addition, both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data. CONCLUSION: Trends in cost-effectiveness are visible but need to be confirmed in future studies. Researchers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the randomization success by reviewing non-cost parameters like clinical data alone.

Does attrition bias longitudinal population-based studies on back pain?

BACKGROUND AND AIMS: Longitudinal population studies are a keystone in describing the course of back pain over time. Yet, potential bias because of repeated attrition has received little attention. This study aims to identify those back pain related indicators most susceptible to bias and to discuss practical consequences for back pain research. METHODS: Analyses were based on a population-based longitudinal multi-centre postal back pain survey with two postal follow-up measurements within 2 years. The baseline sample comprised 9263 subjects. Different sets of measures at entry were used to predict subsequent attrition: Socio-demographic variables, indicators of back pain, health related measures, and response behaviour. Back pain related indicators comprised prevalence estimates, pain intensity, disability, and radiating pain. Weighted and unweighted back pain outcomes were compared at the first and second follow-up to assess bias. RESULTS: Only 52.3% of the eligible participants at baseline continued participation till the second follow-up. Age and prior response behaviour were the best predictors of attrition while health and back pain related variables were of less importance. Differences between weighted and unweighted estimates of back pain related indicators were small to negligible, thus indicating little bias in point estimates. Unexpectedly, the reported back pain burden slightly declined over time. CONCLUSION: The representativeness of the sample is consecutively reduced because of differential attrition over the different measurement points. Despite this, bias due to attrition has a marginal impact on the point estimates of virtually all back pain related outcomes.

Validación del Cuestionario de lugar de control del dolor en estudiantes argentinos con cefaleas recurrentes / Validation of the Pain Locus of Control Questionnaire in Argentinean University Students with Headaches / Validação do Questionário de lugar de controle da dor em estudantes argentinos com dores de cabeça recorrentes

Objetivo. Validar el Cuestionario de lugar de control del dolor (CLCD) en una muestra de estudiantes universitarios argentinos con cefaleas recurrentes. Método. Se empleó un muestreo no probabilístico intencional de 382 estudiantes universitarios de la ciudad de Córdoba (Argentina), que en los últimos seis meses habían sufrido de cefaleas. El 77.7% de la muestra fueron mujeres y el 22.3% varones, con una media de edad de 22.4 años (DE=4.2). Se realizaron estudios para evaluar la estructura interna, consistencia interna y la validez externa del cuestionario. Resultados. El análisis factorial exploratorio mostró tres factores que explicaban un 39.79% de la varianza: (1) locus de control externo por profesionales de la salud, (2) locus de control externo por azar y (3) locus de control interno. Asimismo, los valores alfa de Cronbach para evaluar la consistencia interna de los factores resultaron óptimos (valores α comprendidos entre 0.80 y 0.86).Los análisis realizados para evaluar la validez externa del cuestionario, mediante el coeficiente de correlación de Pearson, revelaron que los factores locus de control externo por profesionales de la salud y los factores locus de control externo por azar correlacionaron positivamente con la intensidad del dolor (r= 0.15, p<0.01; r=0.23, p<0.01, respectivamente), no obstante los valores obtenidos fueron bajos. Conclusión. Aunque presenta limitaciones en su validez externa, los estudios psicométricos realizados permiten concluir que el CLCD es un instrumento confiable y válido para evaluar locus de control en población universitaria argentina con dolor crónico ocasionado por cefaleas.

Objective. This study aims to validate the Pain Locus of Control Questionnaire (PLCQ) in Argentinean university students with recurrent headaches. Method. 382 university students were intentionally selected, 77.7% were females and the 22.3% males, with an average age of 22.4 years old (SD= 4.2). Psychometric studies were developed to evaluate internal structure, internal consistency and external validity. Results. Exploratory factor analysis revealed a factor structure of three dimensions that explained the 39.79% of variance: (1) health professional's external locus of control, (2) hazardous locus of control and (3) internal locus of control. Additionally, Cronbach's α values were observed to be optimal for the three factors of the scale (among 0.80 and 0.86). Although, Pearson's coefficients calculated to evaluate external validity revealed that the factors "health professionals' external locus of control" and "random external locus of control" were significantly and positively correlated to pain intensity (r=0.15/ p<0.01; r= 0.23, p<0.01, respectively), they turned out to be low. Conclusion. The psychometric studies developed in this study suggest that the PLCQ is reliable and valid to be used with Argentinean university students with recurrent headaches. However this study is preliminary, therefore more studies are needed to supplement these findings and to improve its lack of external validity.

Escopo. Validar o Questionário de lugar de controle de dor (QLCD) numa amostra de estudantes universitários argentinos com dores de cabeça recorrentes. Metodologia. Foi empregada uma amostragem não probabilística intencional de 382 estudantes universitários da cidade de Córdoba (Argentina) que nos últimos seis meses têm sofrido dores de cabeça. O 77.7% da amostra foram mulheres e 22.3% homens, com uma média de idade de 22.4 anos de idade (DE= 4.2). Foram realizados estudos para avaliar a estrutura interna, consistência interna e a validez externa do questionário. Resultados. A análise fatorial exploratório mostrou três fatores que explicavam um 39.79% da variação: 1) locus de controle externo por profissionais da saúde, 2) locus de controle externo aleatório e 3) locus de controle interno. Do mesmo jeito os valores alfa de Cronbach para avaliar a consistência interna dos fatores resultaram ótimos (valores α compreendidos entre 0.80 e 0.86). As análises feitas para avaliar a validez externa do questionário, a través do coeficiente de correlação de Pearson, revelaram que os fatores locus de controle externo por profissionais da saúde e os fatores locus de controle externo aleatório correlacionaram positivamente com a intensidade da dor (r= 0.15, p<0.01; r=0.23, p<0.01 respetivamente), contudo, os valores obtidos foram baixos. Conclusão. Embora apresente limitações na sua validez externa, os estudos psicométricos feitos permitem concluir que o QLCD é um instrumento confiável e válido para avaliar locus de controle em população universitária argentina com dor crónica ocasionada por dores de cabeça.

Low back pain in primary care: costs of care and prediction of future health care utilization.

STUDY DESIGN: Cost of illness study alongside a randomized controlled trial. OBJECTIVE: To describe the costs of care for patients with low back pain (1) and to identify patient characteristics as predictors for high health care cost during a 1-year follow-up (2). SUMMARY OF BACKGROUND DATA: Low back pain (LBP) is one of the leading causes of high health care costs in industrialized countries (Life time prevalence, 70%). A lot of research has been done to improve primary health care and patients' prognosis. However, the cost of health care does not necessarily follow changes in patient outcomes. METHODS: General practitioners (n = 126) recruited 1378 patients consulting for LBP. Sociodemographic data, pain characteristics, and LBP-related cost data were collected by interview at baseline and after 6 and 12 months. Costs were evaluated from the societal perspective. Predictors of high cost during the subsequent year were studied using logistic regression analysis. RESULTS: Mean direct and indirect costs for LBP care are about twice as high for patients with chronic LBP compared to acutely ill patients. Indirect costs account for more than 52% to 54% of total costs. About 25% of direct costs refer to therapeutic procedures and hospital or rehabilitational care. Patients with high disability and limitations in daily living show a 2- to 5-fold change for subsequent high health care costs. Depression seems to be highly relevant for direct health care utilization. CONCLUSION: Interventions designed to reduce high health care costs for LBP should focus on patients with severe LBP and depressive comorbidity. Our results add to the economic understanding of LBP care and may give guidance for future actions on health care improvement and cost reduction.

Are fear-avoidance beliefs in low back pain patients a risk factor for low physical activity or vice versa? A cross-lagged panel analysis.

OBJECTIVE: The assumption that low back pain (LBP) patients suffer from "disuse" as a consequence of high fear-avoidance beliefs is currently under debate. A secondary analysis served to investigate whether fear-avoidance beliefs are associated cross-sectionally and longitudinally with the physical activity level (PAL) in LBP patients. METHODS: A total of 787 individuals (57% acute and 43% chronic LBP) were followed up over a period of one year with measurements of fear-avoidance beliefs and physical activity level. Fear-avoidance beliefs concerning physical activity were measured by the physical-activity subscale of the FABQ (Fear-Avoidance Beliefs Questionnaire), the physical activity level was assessed in weighted metabolic equivalents (MET) hours/week with a German self-report questionnaire. Data were investigated by structural equation modelling in a cross-lagged panel design for the whole sample and separately for acute and chronic LBP. RESULTS: The acute and chronic sub sample increased their total physical activity level significantly after one year. The structural equation modelling results did not support the disuse-aspect inherent in the fear-avoidance belief model. Cross-lagged path coefficients were low (.04 and .05 respectively) and, therefore, did not allow to predict final physical activity by initial fear-avoidance beliefs or vice versa. DISCUSSION: Consequently, due to missing links between fear-avoidance beliefs and physical activity in a longitudinal design, the assumptions of the fear-avoidance belief model have to be questioned. These findings are in line with other investigations published recently. Most probably, "fear-avoidance belief" represents a cognitive scheme that does not limit activity per se, but only is directed to the avoidance of specific movements.

The Pain Attitudes and Beliefs Scale for Physiotherapists: psychometric properties of the German version.

OBJECTIVES: To evaluate the psychometric properties of the German version of the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT-G). The original Dutch version is a 36-item self-report scale discriminating between a biomedical and a biopsychosocial orientation of therapists with regard to low back pain management. METHODS: The German version was generated by use of a forward-backward translation procedure. In a cross-sectional study with a repeated measurement after five weeks, a total of 424 physiotherapists got a questionnaire package with the PABS-PT-G as well as the Tampa Scale of Kinesiophobia and patient vignettes. Item and factor analyses served to determine the psychometric properties of the scale. RESULTS: A total of 280 physiotherapists (response rate 79%) completed the questionnaires and a principal component analysis confirmed the two subscales of the original Dutch version. Internal consistency (Cronbach's alpha) of the items belonging to the biomedical factor amounted to 0.77 and to 0.58 for the items of the biopsychosocial factor respectively. Retest reliability showed a coefficient of 0.83 for the biomedical scale and of 0.70 for the biopsychosocial scale. Validity of both subscales of the PABS-PT-G was supported by statistically significant (P<0.01) and substantial correlations with the Tampa Scale of Kinesiophobia and with attitudes of the physiotherapists measured by patient vignettes (r between 0.37 and 0.72). CONCLUSION: The PABS-PT-G appears to be a reliable and valid instrument, which is equivalent to the original Dutch version. Further research is proposed to improve the reliability of the biopsychosocial subscale.

Fear-avoidance beliefs, physical activity, and disability in elderly individuals with chronic low back pain and healthy controls.

OBJECTIVE: Research studies focussing on the fear-avoidance beliefs model (FABM) have expanded considerably during the last years, however, there has been very little research directed at the elderly. The objective of the present study was to investigate the validity of the FABM in older patients with chronic low back pain (CLBP). METHOD: In a cross-sectional study, a group of elderly patients with CLBP (N=103) was compared with an age-matched group of pain-free individuals (N=59) to test the constructs inherent in the FABM. Constructs include fear avoidance beliefs (FABs), disability, disuse, and physical activity. In addition, the relationship of these constructs was also investigated in the patient group. CLBP-patients had an average age of 71.41 years (SD=5.2) and pain-free individuals of 71.19 years (SD=4.73). Individuals participated in a photographed series of physical activities adapted to the age group (Photograph Series of Daily Activities-German version for the elderly) for the assessment of FAB, in the Hannover Disability Questionnaire, in the Freiburg Physical Activity Questionnaire, and in an ultrasound measurement to evaluate lumbar flexion. In addition, they completed an activity diary for 1 week. Before computation, the physical activity measurements were converted into metabolic units that characterize energy expenditure. RESULTS: In the patient group, FAB, pain intensity, and age predicted functional capacity, but not physical activity. Lumbar flexion was predicted by FAB and age. Patients were more fear-avoidant, reported more disability, and displayed less lumbar flexion than the pain-free individuals. No differences between the groups could be detected in regard to energy expenditure measured either by the questionnaire or by diary data. CONCLUSIONS: The findings are consistent with results reported in the literature for younger age groups and confirm the assumption that the FABM is also valid for the elderly.