Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study.

BACKGROUND: Physical therapy influences chronic pain by means of the specific ingredient of an intervention as well as contextual factors including the setting and therapeutic alliance (TA) between provider and patient. OBJECTIVE: The purpose of this study was to compare the effect of enhanced versus limited TA on pain intensity and muscle pain sensitivity in patients with chronic low back pain (CLBP) receiving either active or sham interferential current therapy (IFC). DESIGN: An experimental controlled study with repeated measures was conducted. Participants were randomly divided into 4 groups: (1) AL (n=30), which included the application of active IFC combined with a limited TA; (2) SL (n=29), which received sham IFC combined with a limited TA; (3) AE (n=29), which received active IFC combined with an enhanced TA; and (4) SE (n=29), which received sham IFC combined with an enhanced TA. METHODS: One hundred seventeen individuals with CLBP received a single session of active or sham IFC. Measurements included pain intensity as assessed with a numerical rating scale (PI-NRS) and muscle pain sensitivity as assessed via pressure pain threshold (PPT). RESULTS: Mean differences on the PI-NRS were 1.83 cm (95% CI=14.3-20.3), 1.03 cm (95% CI=6.6-12.7), 3.13 cm (95% CI=27.2-33.3), and 2.22 cm (95% CI=18.9-25.0) for the AL, SL, AE, and SE groups, respectively. Mean differences on PPTs were 1.2 kg (95% CI=0.7-1.6), 0.3 kg (95% CI=0.2-0.8), 2.0 kg (95% CI=1.6-2.5), and 1.7 kg (95% CI=1.3-2.1), for the AL, SL, AE, and SE groups, respectively. LIMITATIONS: The study protocol aimed to test the immediate effect of the TA within a clinical laboratory setting. CONCLUSIONS: The context in which physical therapy interventions are offered has the potential to dramatically improve therapeutic effects. Enhanced TA combined with active IFC appears to lead to clinically meaningful improvements in outcomes when treating patients with CLBP.

Comparative effectiveness of pain management interventions for hip fracture: a systematic review.

BACKGROUND: Pain management is integral to the management of hip fracture. PURPOSE: To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain after hip fracture. DATA SOURCES: 25 electronic databases (January 1990 to December 2010), gray literature, trial registries, and reference lists, with no language restrictions. STUDY SELECTION: Multiple reviewers independently and in duplicate screened 9357 citations to identify randomized, controlled trials (RCTs); nonrandomized, controlled trials (non-RCTs); and cohort studies of pain management techniques in older adults after acute hip fracture. DATA EXTRACTION: Independent, duplicate data extraction and quality assessment were conducted, with discrepancies resolved by consensus or a third reviewer. Data extracted included study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes. DATA SYNTHESIS: 83 unique studies (64 RCTs, 5 non-RCTs, and 14 cohort studies) were included that addressed nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multimodal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2). Overall, moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium. Low-level evidence suggests that preoperative traction does not reduce acute pain. Evidence was insufficient on the benefits and harms of most interventions, including spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy regimens, in managing acute pain. LIMITATIONS: No studies evaluated outcomes of chronic pain or exclusively examined participants from nursing homes or with cognitive impairment. Systemic analgesics (narcotics, nonsteroidal anti-inflammatory drugs) were understudied during the search period. CONCLUSION: Nerve blockade seems to be effective in reducing acute pain after hip fracture. Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.