Systematic Review Procedures for the World Health Organization (WHO) Evidence Syntheses on Benefits and Harms of Structured and Standardized Education/Advice, Structured Exercise Programs, Transcutaneous Electrical Nerve Stimulation (TENS), and Needling Therapies for the Management of Chronic Low Back Pain in Adults.

As commissioned by the WHO, we updated and expanded the scope of four systematic reviews to inform its (in development) clinical practice guideline for the management of CPLBP in adults, including older adults. Methodological details and results of each review are described in the respective articles in this series. In the last article of this series, we discuss methodological considerations, clinical implications and recommendations for future research.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured Exercise Programs for Chronic Primary Low Back Pain in Adults.

PURPOSE: Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE. RESULTS: We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = - 0.33, 95% CI - 0.58 to - 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = - 0.31, 95% CI - 0.57 to - 0.05) (moderate certainty evidence). CONCLUSIONS: With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

Improving Rehabilitation Research to Optimize Care and Outcomes for People with Chronic Primary Low Back Pain: Methodological and Reporting Recommendations from a WHO Systematic Review Series.

Chronic primary low back pain (CPLBP) is a prevalent and disabling condition that often requires rehabilitation interventions to improve function and alleviate pain. This paper aims to advance future research, including systematic reviews and randomized controlled trials (RCTs), on CPLBP management. We provide methodological and reporting recommendations derived from our conducted systematic reviews, offering practical guidance for conducting robust research on the effectiveness of rehabilitation interventions for CPLBP. Our systematic reviews contributed to the development of a WHO clinical guideline for CPLBP. Based on our experience, we have identified methodological issues and recommendations, which are compiled in a comprehensive table and discussed systematically within established frameworks for reporting and critically appraising RCTs. In conclusion, embracing the complexity of CPLBP involves recognizing its multifactorial nature and diverse contexts and planning for varying treatment responses. By embracing this complexity and emphasizing methodological rigor, research in the field can be improved, potentially leading to better care and outcomes for individuals with CPLBP.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults.

PURPOSE: To evaluate benefits and harms of transcutaneous electrical nerve stimulation (TENS) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: We searched for randomized controlled trials (RCTs) from various electronic databases from July 1, 2007 to March 9, 2022. Eligible RCTs targeted TENS compared to placebo/sham, usual care, no intervention, or interventions with isolated TENS effects (i.e., combined TENS with treatment B versus treatment B alone) in adults with CPLBP. We extracted outcomes requested by the WHO Guideline Development Group, appraised the risk of bias, conducted meta-analyses where appropriate, and graded the certainty of evidence using GRADE. RESULTS: Seventeen RCTs (adults, n = 1027; adults ≥ 60 years, n = 28) out of 2010 records and 89 full text RCTs screened were included. The evidence suggested that TENS resulted in a marginal reduction in pain compared to sham (9 RCTs) in the immediate term (2 weeks) (mean difference (MD) = -0.90, 95% confidence interval -1.54 to -0.26), and a reduction in pain catastrophizing in the short term (3 months) with TENS versus no intervention or interventions with TENS specific effects (1 RCT) (MD = -11.20, 95% CI -17.88 to -3.52). For other outcomes, little or no difference was found between TENS and the comparison interventions. The certainty of the evidence for all outcomes was very low. CONCLUSIONS: Based on very low certainty evidence, TENS resulted in brief and marginal reductions in pain (not deemed clinically important) and a short-term reduction in pain catastrophizing in adults with CPLBP, while little to no differences were found for other outcomes.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Needling Therapies for Chronic Primary Low Back Pain in Adults.

PURPOSE: Evaluate benefits and harms of needling therapies (NT) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: Electronic databases were searched for randomized controlled trials (RCTs) assessing NT compared with placebo/sham, usual care, or no intervention (comparing interventions where the attributable effect could be isolated). We conducted meta-analyses where indicated and graded the certainty of evidence. RESULTS: We screened 1831 citations and 109 full text RCTs, yeilding 37 RCTs. The certainty of evidence was low or very low across all included outcomes. There was little or no difference between NT and comparisons across most outcomes; there may be some benefits for certain outcomes. Compared with sham, NT improved health-related quality of life (HRQoL) (physical) (2 RCTs; SMD = 0.20, 95%CI 0.07; 0.32) at 6 months. Compared with no intervention, NT reduced pain at 2 weeks (21 RCTs; MD = - 1.21, 95%CI - 1.50; - 0.92) and 3 months (9 RCTs; MD = - 1.56, 95%CI - 2.80; - 0.95); and reduced functional limitations at 2 weeks (19 RCTs; SMD = - 1.39, 95%CI - 2.00; - 0.77) and 3 months (8 RCTs; SMD = - 0.57, 95%CI - 0.92; - 0.22). In older adults, NT reduced functional limitations at 2 weeks (SMD = - 1.10, 95%CI - 1.71; - 0.48) and 3 months (SMD = - 1.04, 95%CI - 1.66; - 0.43). Compared with usual care, NT reduced pain (MD = - 1.35, 95%CI - 1.86; - 0.84) and functional limitations (MD = - 2.55, 95%CI - 3.70; - 1.40) at 3 months. CONCLUSION: Based on low to very low certainty evidence, adults with CPLBP experienced some benefits in pain, functioning, or HRQoL with NT; however, evidence showed little to no differences for other outcomes.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured and Standardized Education or Advice for Chronic Primary low back pain in Adults.

PURPOSE: Evaluate benefits and harms of education/advice for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: Electronic databases were searched for randomized controlled trials (RCTs) assessing education/advice compared with placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of education/advice could be isolated). We conducted meta-analyses and graded the certainty of evidence. RESULTS: We screened 2514 citations and 86 full text RCTs and included 15 RCTs. Most outcomes were assessed 3 to 6 months post-intervention. Compared with no intervention, education/advice improved pain (10 RCTs, MD = -1.1, 95% CI -1.63 to -0.56), function (10 RCTs, SMD = -0.51, 95% CI -0.89 to -0.12), physical health-related quality of life (HRQoL) (2 RCTs, MD = 24.27, 95% CI 12.93 to 35.61), fear avoidance (5 RCTs, SMD = -1.4, 95% CI -2.51 to -0.29), depression (1 RCT; MD = 2.10, 95% CI 1.05 to 3.15), and self-efficacy (1 RCT; MD = 4.4, 95% CI 2.77 to 6.03). Education/advice conferred less benefit than sham Kinesio taping for improving fear avoidance regarding physical activity (1 RCT, MD = 5.41, 95% CI 0.28 to 10.54). Compared with usual care, education/advice improved pain (1 RCT, MD = -2.10, 95% CI -3.13 to -1.07) and function (1 RCT, MD = -7.80, 95% CI -14.28 to -1.32). There was little or no difference between education/advice and comparisons for other outcomes. For all outcomes, the certainty of evidence was very low. CONCLUSION: Education/advice in adults with CPLBP was associated with improvements in pain, function, HRQoL, and psychological outcomes, but with very low certainty.

[Chronic pain and the social context]. / Douleurs chroniques en contexte : du côté du social.

The chronic pain complaint is still poorly accepted in the community and even sometimes in the health care system. It may trigger reactions of disbelief, suspicion or rejection. The legitimization and validation of the patient's suffering is a priority in order for him/her to feel believed and understood and improve his/her commitment to the treatment proposal. The social consequences of chronic pain include various limitations, a reduction of activities, of personal and professional ties leading to social exclusion amplifying the painful experience. Exploring his/her social context during the consultation often helps the patient to re-establish significant links. It leads to wider therapeutic approaches focusing on the strengthening of social support, with documented benefits on pain experience, mood and quality of life.

La plainte douloureuse chronique reste souvent mal acceptée dans le champ social et parfois même dans le système de soins. Elle peut rencontrer de l'incrédulité, de la suspicion et du rejet. Sa légitimation est prioritaire afin de donner au patient le sentiment d'être cru et entendu et d'améliorer son engagement dans un projet thérapeutique partagé. Les conséquences sociales de la douleur chronique comprennent des limitations diverses et une modification des activités et des liens personnels et professionnels qui peuvent mener à des situations d'exclusion sociale amplifiant l'expérience douloureuse. L'exploration du contexte permet d'aider le patient à renouer des liens et d'orienter les approches thérapeutiques vers un renforcement du soutien social dont les bénéfices sur le vécu douloureux, l'humeur et la qualité de vie sont documentés.

[Therapeutic alliance and cognitive behavioral group therapy]. / Alliance thérapeutique et thérapie cognitivo-comportementale de groupe.

In cognitive-behavioral group therapy, the therapeutic alliance with the psychotherapists and between the patients in the group, allows patients to develop coping strategies. These include cognitive and behavioral efforts aimed to control, reduce or tolerate specific demands, whether internal or external, experienced as threatening, exhausting or exceeding the patient's resources. This adaptive mechanism lowers the intensity of anxiety, favors control of fear and reinforces the motivation and energy invested in the process of change. We describe the importance of therapeutic alliance in group therapy with patients suffering from chronic pain. These processes will be illustrated with clinical vignettes.

Lors de thérapie cognitivo-comportementale de groupe, l'alliance thérapeutique, avec les psychothérapeutes et entre les patients, permet à ces derniers de développer leurs capacités de coping, c'est-à-dire l'ensemble des efforts cognitifs et comportementaux destinés à maîtriser, réduire ou tolérer des demandes spécifiques internes et/ou externes, vécues par le sujet comme menaçantes, épuisantes ou dépassant ses ressources. Cette alliance fonctionne en tant que mécanisme adaptatif permettant de diminuer l'intensité de l'anxiété, favoriser le contrôle des peurs et renforcer la motivation et l'énergie investies dans le processus de changement. Nous décrivons l'importance de cette alliance thérapeutique dans le processus groupal réunissant des thérapeutes et des patients souffrant de douleurs chroniques. Ces mouvements seront illustrés par des vignettes cliniques.

Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients With Nonacute Musculoskeletal Conditions? A Systematic Rapid Review.

OBJECTIVE: To determine whether nonpharmacologic interventions delivered through synchronous telehealth are as effective and safe compared with in-person interventions for the management of patients with musculoskeletal conditions in improving pain, functioning, self-reported recovery, psychological outcomes, or health-related quality of life using rapid review methods. DATA SOURCES: We searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials from 2010 to August 2020 for randomized controlled trials (RCTs) published in English or French; we updated our search in January 2021. STUDY SELECTION: One reviewer screened citations in 2 phases (phase 1: title/abstract; phase 2: full-text) selecting RCTs comparing synchronous telehealth with in-person care for the management of musculoskeletal conditions. A random 10% sample was screened by 2 independent reviewers with minimum 95% agreement prior to full screening. One reviewer critically appraised and one reviewer validated appraisal for eligible RCTs. DATA EXTRACTION: One author extracted participant characteristics, setting, sample size, interventions, comparisons, follow-up period, and outcome data. A second author validated data extraction. DATA SYNTHESIS: We summarized the findings narratively. Low- to moderate-quality evidence suggests that synchronous telehealth (ie, videoconference or telephone calls) alone or in combination with in-person care leads to similar outcomes as in-person care alone for nonspecific low back pain, generalized osteoarthritis, hip or knee osteoarthritis, and nonacute headaches in adults. CONCLUSIONS: Synchronous telehealth may be an option for the management of nonacute musculoskeletal conditions in adults. However, our results may not be generalizable to rural or low socioeconomic populations. Future research should investigate the outcomes associated the use of new technologies, such as videoconference.

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.

Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review.

CONTEXT: Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence. AIM: To identify determinants of clinical practice guidelines' utilization by health care providers involved in the assessment and management of MSDs. METHOD: A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines' utilization were extracted from selected articles. RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with "non-specific" term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician's interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language. CONCLUSION: Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

[On some links between pain and emotions]. / De quelques liens entre douleurs et emotions.

The entanglement between pain and emotions is increasingly recognized. Emotions can predispose to pain and contribute to its chronicisation but also to its relief. The placebo effect is a witness to the moderating influences of cognitions and emotions on pain. An awareness of these influences is of interest to patients as it can widen their therapeutic perspectives. Chronic refractory pain has often been linked to a history of abuse, neglect and psychological trauma whose neuropsychological and affective traces can predispose to painful complaints. The treatment approach requires strong commitment and empathy on the part of the therapist in order to help patients reconnect with their own history and their emotions.

L'intrication entre douleurs et émotions est de mieux en mieux reconnue. Les émotions représentent des facteurs de vulnérabilité et de persistance de la douleur autant que des alliées de son soulagement. L'effet placebo est un témoin des influences modératrices des cognitions et émotions sur la douleur. L'utilisation de ces influences peut être présentée aux patients comme un élargissement des possibilités thérapeutiques. Il arrive que les douleurs chroniques rebelles soient les indices de la persistance d'une souffrance liée à des expériences traumatiques, de maltraitance ou d'abandon infantile, dont les traces neuropsychologiques et affectives prédisposent aux plaintes douloureuses. La prise en charge nécessite un engagement empathique et attentif du thérapeute pour permettre aux patients de renouer avec leur histoire et leurs émotions.

[Personalized approach in chronic pain psychotherapy]. / Approche personnalisée dans la psychothérapie des douleurs chroniques.

Chronic pain is a complex phenomenon that includes three dimensions : biological, socio-cultural and psychological. The psychological aspect plays an amplifying role in the perception of pain and therefore, adjuvant psychotherapies are an important tool in the multidimensional management of chronic pain. In this article, we present the main psychotherapeutic approaches and techniques applied in the field of chronic pain which act on the cognitive-emotional, traumatic, as well as on the sensory level. The personalization of psychotherapeutic treatment, as well as the involvement of patients in its choice, should allow psychotherapeutic approaches to achieve their goal in terms of improving the quality of life of patients.

La douleur chronique est un phénomène complexe qui inclut trois dimensions : biologique, socioculturelle et psychologique. L'aspect psychologique joue un rôle amplificateur dans la perception douloureuse et de ce fait, les psychothérapies adjuvantes constituent un outil important quant à la prise en charge multidimensionnelle de la douleur chronique. Dans cet article, nous présentons les approches et techniques psychothérapeutiques principales appliquées dans le domaine de la douleur chronique qui agissent tant sur le plan cognitivo-émotionnel et traumatique que sur le plan sensoriel. La personnalisation du traitement psychothérapeutique ainsi que l'implication des patients dans son choix devraient permettre aux approches psychothérapeutiques d'atteindre leur objectif en termes d'amélioration de la qualité de vie des patients.

[Activity, decentration and cognitive restructuring in cognitive-behavioural therapy - practice-based aspects]. / Activité, décentration et restructuration cognitive dans la thérapie cognitivocomportementale - Éléments pour la pratique clinique.

Decentration and cognitive restructuring are used in cognitive-behavioural therapy (CBT) with patients suffering from chronic pain and are reinforced by group work. They can also be useful to the general practitioner. Clinical vignettes summarize the role of group CBT in identifying realistic and meaningful activities. They stress decentration and cognitive restructuring as key therapeutic tools in group CBT. Using them with patients suffering from chronic pain is complex and challenging when it comes to allow the patients to overcome the impossibility to function 'as before' while figuring out how to cope 'as for now'.

La décentration et la restructuration cognitive sont utilisées dans les thérapies cognitivocomportementales (TCC) chez les patients souffrant de douleurs chroniques et sont renforcées par le travail en groupe. Elles peuvent également être utilisées par les praticiens dans leurs cabinets. Des vignettes cliniques résument leur rôle dans l'identification d'activités réalistes et significatives et posent la décentration et la restructuration cognitive en tant qu'outils d'intérêt pour la TCC de groupe. Leur utilisation avec des patients douloureux chroniques peut permettre aux patients de surmonter l'impossibilité à faire « comme avant ¼ pour s'imaginer parvenir à gérer « comme maintenant ¼.

Covering patient's perspective in case-based critical review articles to improve shared decision making in complex cases.

BACKGROUND: The patient has always been at the centre of the evidence-based medicine model. Case-based critical reviews, such as best-evidence topics, however, are incomplete reflections of the evidence-based medicine philosophy, because they fail to consider the patient's perspective. We propose a new framework, called the 'Shared Decision Evidence Summary' (ShaDES), where the patient's perspective on available treatment options is explicitly included. METHODS: Our framework is grounded in the critical appraisal of a clinical scenario, and the development of a clinical question, including patient characteristics, compared options and outcomes to be improved. Answers to the clinical question are informed by the literature, the evaluation of its quality and its potential usefulness to the clinical scenario. Finally, the evidence synthesis is presented to the patient to facilitate the formulation of an evidence-informed decision about the treatment options. KEY RESULTS: Using three similar but contrasted clinical scenarios of patients with low back pain, we illustrate how considering the patient's preferences on the proposed treatment options impact the bottom line, a synthetic formulation of the answer to the focused question. ShaDES includes clinical and psychosocial components, transformed in a searchable question, with a full search strategy. CONCLUSIONS: ShaDES is a practical framework that may facilitate clinical decisions adapted to psychological, social and other relevant non-clinical characteristics of patients.

[Mobile applications and self-management of chronic pain]. / Applications mobiles et autogestion des douleurs chroniques.

Self-management of chronic pain should enable patients to regain an acceptable quality of life, autonomy, and reduce the number of consultations. These strategies are increasingly available on mobile applications, which have been evaluated for their content and effectiveness in several reviews. The vast majority of applications offer only one self-management strategy, few opportunities for interactions, and have not involved patients and healthcare professionals in their development. It is therefore still difficult to determine their effectiveness in the self-management of chronic pain. However, mobile applications should not be neglected. On the contrary, it is necessary to develop validated applications in French considering the five criteria classically recommended for self-management. Then such applications can be prescribed by health professionals as part of the multimodal management of chronic pain.

L'autogestion des douleurs chroniques doit permettre aux patients de retrouver une qualité de vie acceptable, une autonomie, et de diminuer les consultations. Ces stratégies sont de plus en plus disponibles sur des applications mobiles dont plusieurs revues ont évalué le contenu et l'efficacité. Il en ressort que la grande majorité des applications ne proposent qu'une seule stratégie d'autogestion, offrent peu de possibilités d'interactions, et n'ont pas impliqué dans leur développement patients ou professionnels de la santé. Il est ainsi encore difficile de déterminer leur efficacité dans l'autogestion des douleurs chroniques. Cependant, les applications mobiles ne sont pas un moyen à négliger, il faut au contraire développer des applications validées en français tenant compte des cinq critères classiquement recommandés pour l'autogestion. Alors de telles applications pourront être prescrites par les professionnels de la santé dans le cadre de la prise en charge multimodale des douleurs chroniques.

[Why propose cognitive-behavioural therapy for chronic pain patients†?] / Pourquoi proposer la thérapie cognitivo-comportementale dans les douleurs chroniques ?

Cognitive and behavioral techniques (CBT) are used in the approach of chronic pain, based on the assumption that pain and disability are not (only) influenced by somatic issues but also by psychosocial factors. CBT aim to improving quality of life while targeting disability. Psychoeducation, activity-centered and cognitive techniques are central, drawing on the identification of an activity that is not only important and meaningful for the patient but also realistic. This should allow the patient to overcome the impossibility to function «â€…as before ¼ while figuring out how to cope «â€…as for now ¼. The ways to explore possible alternative options during the group therapy is presented and discussed.

Les techniques cognitives et comportementales (TCC) sont utilisées dans l'approche des douleurs chroniques, sur la base du postulat que douleur et handicap ne sont pas (uniquement) influencés par la pathologie somatique, mais aussi par des facteurs psychosociaux. Les TCC visent à l'amélioration de la qualité de vie, au-travers d'une réduction du handicap. La dimension psychoéducative, les techniques centrées sur l'activité et les techniques cognitives y tiennent une place centrale, reposant sur le choix d'une activité importante et qui fasse du sens pour le patient, autour d'objectifs réalistes, et qui permettent au patient de dépasser l'impossibilité de faire «â€…comme avant ¼ pour imaginer des façons de faire «â€…comme maintenant ¼. La manière dont l'exploration du champ des possibles est abordée au fil des séances est présentée et discutée.

[Demoralization and meaning in life in suicidal ideation†: a role for patients suffering from chronic pain?] / Démoralisation et sens dans la vie dans l'idéation suicidaire†: un role chez les patients douloureux chroniques†?

Chronic pain is strongly related to the emotional state of the individual and may be associated with suicidal ideation. The concepts of demoralization and meaning in life may have a role in suicidal ideation as a factor of crisis and resilience, respectively. Demoralization, and especially one of its elements, hopelessness, predisposes to suicidal behavior and is often associated with chronic pain conditions. In addition, the meaning that a patient with chronic pain attributes to his or her existence may also influence suicidal behavior. Follow-ups focused on demoralization and meaning in life may be a promising psychotherapeutic approach for patients suffering from chronic pain.

La douleur chronique est fortement liée à l'état émotionnel de l'individu et peut être associée à l'idéation suicidaire. Les concepts de démoralisation et de sens dans la vie peuvent avoir un rôle sur l'idéation suicidaire respectivement en tant que facteur de crise et de résilience. La démoralisation, et surtout l'un de ses éléments, le désespoir, prédispose au comportement suicidaire et est souvent associée à des états douloureux chroniques. En outre, le sens qu'un patient souffrant de douleurs chroniques peut attribuer à son existence peut également influencer le comportement suicidaire. Une prise en charge centrée sur la démoralisation et le sens dans la vie pourrait constituer une approche psychothérapeutique prometteuse pour les patients souffrant de douleurs chroniques.

The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities.

PURPOSE: The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain. METHODS: We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries. RESULTS: Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction. CONCLUSION: Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities.

PURPOSE: The purpose of this review was to describe psychological and social factors associated with low back pain that could be applied in spine care programs in medically underserved areas and low- and middle-income countries. METHODS: We performed a narrative review of cohort, cross-sectional, qualitative and mixed methods studies investigating adults with low back pain using Medline and PubMed were searched from January 2000 to June 2015. Eligible studies had at least one of the following outcomes: psychological, social, psychosocial, or cultural/ethnicity factors. Studies met the following criteria: (1) English language, (2) published in peer-reviewed journal, (3) adults with spinal disorders, (4) included treatment, symptom management or prevention. RESULTS: Out of 58 studies, 29 were included in this review. There are few studies that have evaluated psychological and social factors associated with back pain in low- and middle-income communities, therefore, adapting recommendations from other regions may be needed until further studies can be achieved. CONCLUSION: Psychological and social factors are important components to addressing low back pain and health care providers play an important role in empowering patients to take control of their spinal health outcomes. Patients should be included in negotiating their spinal treatment and establishing treatment goals through careful listening, reassurance, and information providing by the health care provider. Instruments need to be developed for people with low literacy in medically underserved areas and low- and middle-income countries, especially where psychological and social factors may be difficult to detect and are poorly addressed. These slides can be retrieved under Electronic Supplementary Material.