Multidisciplinary biopsychosocial rehabilitation for subacute low back pain.

BACKGROUND: Low back pain (LBP) is associated with enormous personal and societal burdens, especially when it reaches the chronic stage of the disorder (pain for a duration of more than three months). Indeed, individuals who reach the chronic stage tend to show a more persistent course, and they account for the majority of social and economic costs. As a result, there is increasing emphasis on the importance of intervening at the early stages of LBP.According to the biopsychosocial model, LBP is a condition best understood with reference to an interaction of physical, psychological, and social influences. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.This review is an update of a Cochrane Review on MBR for subacute LBP, which was published in 2003. It is part of a series of reviews on MBR for musculoskeletal pain published by the Cochrane Back and Neck Group and the Cochrane Musculoskeletal Group. OBJECTIVES: To examine the effectiveness of MBR for subacute LBP (pain for a duration of six to 12 weeks) among adults, with a focus on pain, back-specific disability, and work status. SEARCH METHODS: We searched for relevant trials in any language by a computer-aided search of CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and two trials registers. Our search is current to 13 July 2016. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of adults with subacute LBP. We included studies that investigated a MBR program compared to any type of control intervention. We defined MBR as an intervention that included a physical component (e.g. pharmacological, physical therapy) in combination with either a psychological, social, or occupational component (or any combination of these). We also required involvement of healthcare professionals from at least two different clinical backgrounds with appropriate training to deliver the component for which they were responsible. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. In particular, the data extraction and 'risk of bias' assessment were conducted by two people, independently. We used the Cochrane tool to assess risk of bias and the GRADE approach to assess the overall quality of the evidence for each outcome. MAIN RESULTS: We included a total of nine RCTs (981 participants) in this review. Five studies were conducted in Europe and four in North America. Sample sizes ranged from 33 to 351. The mean age across trials ranged between 32.0 and 43.7 years.All included studies were judged as having high risk of performance bias and high risk of detection bias due to lack of blinding, and four of the nine studies suffered from at least one additional source of possible bias.In MBR compared to usual care for subacute LBP, individuals receiving MBR had less pain (four studies with 336 participants; SMD -0.46, 95% CI -0.70 to -0.21, moderate-quality of evidence due to risk of bias) and less disability (three studies with 240 participants; SMD -0.44, 95% CI -0.87 to -0.01, low-quality of evidence due to risk of bias and inconsistency), as well as increased likelihood of return-to-work (three studies with 170 participants; OR 3.19, 95% CI 1.46 to 6.98, very low-quality of evidence due to serious risk of bias and imprecision) and fewer sick leave days (two studies with 210 participants; SMD -0.38 95% CI -0.66 to -0.10, low-quality of evidence due to risk of bias and imprecision) at 12-month follow-up. The effect sizes for pain and disability were low in terms of clinical meaningfulness, whereas effects for work-related outcomes were in the moderate range.However, when comparing MBR to other treatments (i.e. brief intervention with features from a light mobilization program and a graded activity program, functional restoration, brief clinical intervention including education and advice on exercise, and psychological counselling), we found no differences between the groups in terms of pain (two studies with 336 participants; SMD -0.14, 95% CI -0.36 to 0.07, low-quality evidence due to imprecision and risk of bias), functional disability (two studies with 345 participants; SMD -0.03, 95% CI -0.24 to 0.18, low-quality evidence due to imprecision and risk of bias), and time away from work (two studies with 158 participants; SMD -0.25 95% CI -0.98 to 0.47, very low-quality evidence due to serious imprecision, inconsistency and risk of bias). Return-to-work was not reported in any of the studies.Although we looked for adverse events in both comparisons, none of the included studies reported this outcome. AUTHORS' CONCLUSIONS: On average, people with subacute LBP who receive MBR will do better than if they receive usual care, but it is not clear whether they do better than people who receive some other type of treatment. However, the available research provides mainly low to very low-quality evidence, thus additional high-quality trials are needed before we can describe the value of MBP for clinical practice.

A Systematic Review of the Prospective Relationship Between Bullying Victimization and Pain.

OBJECTIVE: This systematic review synthesized evidence about the relationship between childhood bullying victimization and chronic pain, with a focus on the temporal nature of the relationship and moderating factors, such as the type and intensity of victimization. METHOD: We included prospective cohort studies that examined the relationship between childhood bullying victimization and pain measured at least three months later. We conducted electronic searches of Medline, EMBASE, PsycINFO, and CINAHL up to June 30, 2019. Standard methodological procedures consistent with Cochrane reviews of prognosis studies were used (PROSPERO record ID 133146). RESULTS: We included four longitudinal studies (6275 participants) in this review. The mean age of participants at baseline ranged from 10 to 14 years and the follow-up periods ranged from 6 months to 12 years. Two of the four studies were judged as having high risk of bias. Meta-analysis of results from four studies revealed increased risk of pain among victimized compared to non-victimized youth (adjusted OR [95% CI] = 1.45 [1.06-1.97], but the effect size was small and not clinically important. Only one study examined the inverse association (ie, from pain to victimization), and there was not enough evidence to conduct a meaningful analysis of the proposed moderators. CONCLUSIONS: Study findings were limited by few prospective studies. Meta-analytic findings suggested that victimization may incur some risk for later pain, although the evidence was judged to be very low quality. High-quality studies that measure and report the nuances of bullying victimization are needed to test the proposed moderator models.

A Systematic Review of the Prospective Relationship between Child Maltreatment and Chronic Pain.

OBJECTIVE: The present systematic review aimed to evaluate the association between childhood maltreatment and chronic pain, with specific attention to the temporal nature of the relationship and putative moderators, including, the nature (type), timing of occurrence, and magnitude of maltreatment; whether physical harm or injury occurred; and whether post-traumatic stress disorder (PTSD) subsequently developed. METHOD: We included studies that measured the prospective relationship between child maltreatment and pain. Medline, EMBASE, PsycINFO, and CINAHL were searched electronically up to 28 July 2019. We used accepted methodological procedures common to prognosis studies and preregistered our review (PROSPERO record ID 142169) as per Cochrane review recommendations. RESULTS: Nine studies (17,340 participants) were included in the present review. Baseline participant age ranged from 2 years to more than 65 years. Follow-up intervals ranged from one year to 16 years. Of the nine studies included, three were deemed to have a high risk of bias. With the exception of one meta-analysis of three studies, results were combined using narrative synthesis. Results showed low to very low quality and conflicting evidence across the various types of maltreatment, with the higher quality studies pointing to the absence of direct (non-moderated and non-mediated) associations between maltreatment and pain. PTSD was revealed to be a potential mediator and/or moderator. Evidence was not found for other proposed moderators. CONCLUSIONS: Overall, there is an absence of evidence from high quality studies of an association between maltreatment and pain. Our results are limited by the small number of studies reporting the relationship between child maltreatment and pain using a prospective design. High quality studies, including prospective cohort studies and those that assess and report on the moderators described above, are needed to advance the literature.

Double-exposure to acute stress and chronic family stress is associated with immune changes in children with asthma.

OBJECTIVE: To understand how psychological stress heightens risk for asthma flare-ups, we examined the relationship between acute stress, chronic family stress, and the production of asthma-related cytokines. METHODS: Seventy-one children with asthma and 76 medically healthy children completed interviews regarding life stress, and peripheral blood samples were collected. After mononuclear cells had been mitogenically stimulated, production of the cytokines interleukin (IL)-4, IL-5, IL-13, and IFN-gamma was measured. All measurements were repeated every 6 months for 2 years. Children reported on their asthma symptoms for 14 days after each study visit. RESULTS: Children with asthma who had higher levels of chronic family stress showed increased production of IL-4, IL-5, and IFN-gamma at times when they had experienced an acute event compared with times when they had not. These stress-related changes did not occur in asthmatic children with lower levels of chronic family stress, or in healthy controls. The combination of acute and chronic stress was also associated with increased asthma symptoms. CONCLUSION: These findings suggest that acute negative life events have a particularly strong impact among a subgroup of children with asthma who are under high chronic family stress. The heightened inflammatory profile in this group suggests an explanation for why children experiencing life stressors are at greater risk for asthma exacerbations.

What do trajectories of childhood socioeconomic status tell us about markers of cardiovascular health in adolescence?

OBJECTIVE: The current study examined trajectories of socioeconomic status (SES) throughout childhood and their relationship to markers of cardiovascular health in adolescence. The goal was to determine whether early-life SES, current SES, cumulative SES, and/or social mobility best explained the relationship between SES experiences across an adolescent's life span and current blood pressure (BP), heart rate (HR), and body mass index (BMI). DESIGN: One hundred two adolescents completed cardiovascular health assessments including systolic blood pressure, diastolic blood pressure, HR, and BMI. Parents reported on family SES, indicating the number of bedrooms in the family home for each year of the child's life. RESULTS: Using Jones, Nagin, and Roeder's semiparametric group-based method, four distinct trajectories of childhood SES were identified. Trajectory groups were differentially related to adolescents' systolic blood pressure and diastolic blood pressure. A trajectory showing low early-life SES that increased through childhood was associated with the highest BP in adolescence. Partial correlation analyses specifically examining the various life-course scenarios similarly indicated that early-life SES was the strongest predictor of adolescents' BP. Trajectories of childhood SES were unrelated to HR and BMI. CONCLUSIONS: Of the life-course models that we tested, an early-life SES model best explained adolescents' current BP. These findings point toward early-life developmental processes as potential candidates for explaining the relationship between SES and risk factors related to cardiovascular disease. They suggest that interventions designed to reduce SES health disparities should take place early in a child's life.

Differentiating the impact of episodic and chronic stressors on hypothalamic-pituitary-adrenocortical axis regulation in young women.

OBJECTIVE: The goal of this study was to examine the impact of episodic stress and chronic interpersonal stress on indices of HPA regulation. To explore the potential downstream consequences of altered HPA dynamics, the authors also assessed indicators of metabolic control and systemic inflammation. DESIGN: One hundred four medically healthy women between the ages of 15 and 19 participated. Following an in-depth interview of life stress, a sample of blood was drawn through antecubital venipuncture. Over the course of the next 2 days, participants gathered salivary cortisol samples. MAIN OUTCOME MEASURES: Cortisol morning response, cortisol daily output, glucocorticoid receptor (GR) mRNA, C-reactive protein (CRP), insulin, and glucose. RESULTS: The simple presence of episodic stress or chronic interpersonal stress was not reliably associated with cortisol output, GR mRNA, insulin, or glucose. When women were exposed to an episodic stressor in the midst of chronic stress they showed increased cortisol output and reduced expression of GR mRNA. By contrast, when women had low levels of chronic stress, episodic events were associated with decreased cortisol output and increased GR mRNA. Episodic and chronic stress also interacted to predict CRP, but not insulin or glucose. CONCLUSIONS: The impact of episodic stress is accentuated in the midst of chronic interpersonal stress and diminished in its absence. Simultaneous exposure to episodic and chronic stress may create wear and tear on the body, whereas exposure to episodic stress in the context of a supportive environment may toughen the body, protecting it against subsequent stressors.

Taking the middle ground, where the path is most clear: reply to Smith (2013) and Denollet (2013).

We appreciate the thoughtful comments on Marin and Miller (2013). Both commentaries questioned the validity of our conclusions about interpersonal sensitivity (IS) and health, with Smith (2013) arguing that we overstated the conclusions and Denollet (2013) arguing that we did not take them far enough. Here we offer a middle-ground approach to interpreting the IS-health literature. We discuss our rationale for including introversion as an IS construct, and we point readers to high-quality evidence that specifically rules out some of the competing explanations raised by Smith (2013). Finally, we argue that additional work in this area is needed before specific hypotheses about biological mechanisms and the roles of age and disease stage as possible moderators can be tested.

The interpersonally sensitive disposition and health: an integrative review.

This article reviews studies that have examined the association between constructs related to interpersonal sensitivity (IS) and morbidity and mortality from major medical illnesses. We define IS as a stable trait characterized by ongoing concerns about negative social evaluation. This disposition makes people vigilant for as well as sensitive to others' evaluations of them. To avoid negative social evaluation, they adopt defensive behaviors such as submission and inhibition. Aspects of IS are captured by various constructs, including introversion, rejection sensitivity, social inhibition, social anxiety, and submissiveness. The review includes 76 long-term prospective studies across 4 outcome categories, namely, infectious disease, cancer, cardiovascular disease (CVD), and all-cause mortality. Three general conclusions are established. First, IS individuals are at increased risk of infectious diseases and possibly CVD, but not cancer and not all-cause mortality. Second, the positive studies provide evidence that IS temporally precedes disease, and go a long way toward ruling out the most plausible alternative explanations based on confounders, supporting a tentative causal interpretation of the data. However, unmeasured potential confounders make it impossible to be certain about whether IS drives the effects on mortality and morbidity. Third, the effects of introversion are accentuated and may only become apparent in contexts that activate social-evaluative concerns (e.g., exposure to early life residential mobility, living with the stigma of human immunodeficiency virus). Findings are discussed in regard to potential psychosocial and psychobiological mechanisms as well as implications for future work concerning IS and health.

Biologic cost of caring for a cancer patient: dysregulation of pro- and anti-inflammatory signaling pathways.

PURPOSE: Caring for a family member with cancer is a psychologically demanding experience. However, it remains unclear whether the distress that caregiving provokes also takes a physiologic toll on the body. This study observed familial caregivers of patients with brain cancer for a year after diagnosis and tracked changes in neurohormonal and inflammatory processes. PATIENTS AND METHODS: Eighteen caregivers (age 50.4 +/- 3.5 years) and 19 controls (age 50.2 +/- 2.6 years) were assessed four times during a year (before and after radiotherapy, as well as 6 weeks and 4 months thereafter). Salivary biomarkers of hypothalamus-pituitary-adrenal axis and sympathetic nervous system (SNS) activity were collected, and blood was drawn for assessment of the systemic inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6). Blood was also used to monitor in vitro IL-6 production by endotoxin-stimulated leukocytes and expression of mRNA for pro- and anti-inflammatory signaling molecules. RESULTS: Caregivers showed marked changes over time in diurnal output of salivary amylase, a marker of SNS activity, whereas secretions in controls were stable during follow-up. Cortisol output was similar in caregivers and controls. During the year, caregivers showed a profound linear increase in systemic inflammation, as indexed by CRP. At the same time, they displayed a linear decline in mRNA for anti-inflammatory signaling molecules and diminished in vitro glucocorticoid sensitivity. CONCLUSION: These preliminary data show that familial caregivers of patients with cancer experience marked changes in neurohormonal and inflammatory processes in the year after diagnosis. These changes may place them at risk for morbidity and mortality from diseases fostered by excessive inflammation.