Cognitive-behavioral Treatment for Subacute and Chronic Neck Pain: A Cochrane Review.

STUDY DESIGN: Systematic review of randomized-controlled trials (RCTs). OBJECTIVE: To assess the effects of cognitive-behavioral therapy (CBT) on neck pain (NP). SUMMARY OF BACKGROUND DATA: Although research on nonpharmacological and nonsurgical treatments for NP is progressing, there remains uncertainty about the efficacy of CBT. METHODS: We searched electronic databases for RCTs. We included RCTs assessing the use of CBT on adults with subacute and chronic NP. 2 independent reviewers extracted data on pain (primary outcome), disability, psychological indicator, and quality of life. We calculated standardized mean differences and 95% confidence intervals. We used the Cochrane Collaboration's tool to assess risk of bias and the GRADE approach to evaluate the quality of evidence and summarize conclusions. RESULTS: We included 10 studies (836 participants), 4 at low risk of bias. With regard to chronic NP, there was low quality evidence that CBT was better than no treatment for improving pain, disability, and quality of life, whereas no effect was found on kinesiophobia. The clinical importance of these benefits is uncertain. When comparing both CBT to other interventions and CBT in addition to another intervention to the other intervention alone, no difference was found for pain and disability, whereas a positive effect was achieved for kinesiophobia only when comparing CBT with other interventions. On subacute NP, CBT was found to be better than other interventions for pain, whereas no difference was found for secondary outcomes. CONCLUSION: CBT was shown to induce changes on pain and disability for chronic NP only when compared with no treatment. On subacute NP, benefit was found on pain relief but not on disability when comparing CBT with other interventions. However, none of these effects were clinically meaningful. Due to the low quality of the evidence, our conclusions might change over time whereas new data are available. LEVEL OF EVIDENCE: 1.

Cognitive-behavioural treatment for subacute and chronic neck pain.

BACKGROUND: Although research on non-surgical treatments for neck pain (NP) is progressing, there remains uncertainty about the efficacy of cognitive-behavioural therapy (CBT) for this population. Addressing cognitive and behavioural factors might reduce the clinical burden and the costs of NP in society. OBJECTIVES: To assess the effects of CBT among individuals with subacute and chronic NP. Specifically, the following comparisons were investigated: (1) cognitive-behavioural therapy versus placebo, no treatment, or waiting list controls; (2) cognitive-behavioural therapy versus other types of interventions; (3) cognitive-behavioural therapy in addition to another intervention (e.g. physiotherapy) versus the other intervention alone. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, and PubMed, as well as ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2014. Reference lists and citations of identified trials and relevant systematic reviews were screened. SELECTION CRITERIA: We included randomised controlled trials that assessed the use of CBT in adults with subacute and chronic NP. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach. MAIN RESULTS: We included 10 randomised trials (836 participants) in this review. Four trials (40%) had low risk of bias, the remaining 60% of trials had a high risk of bias.The quality of the evidence for the effects of CBT on patients with chronic NP was from very low to moderate. There was low quality evidence that CBT was better than no treatment for improving pain (standard mean difference (SMD) -0.58, 95% confidence interval (CI) -1.01 to -0.16), disability (SMD -0.61, 95% CI -1.21 to -0.01), and quality of life (SMD -0.93, 95% CI -1.54 to -0.31) at short-term follow-up, while there was from very low to low quality evidence of no effect on various psychological indicators at short-term follow-up. Both at short- and intermediate-term follow-up, CBT did not affect pain (SMD -0.06, 95% CI -0.33 to 0.21, low quality, at short-term follow-up; MD -0.89, 95% CI -2.73 to 0.94, low quality, at intermediate-term follow-up) or disability (SMD -0.10, 95% CI -0.40 to 0.20, moderate quality, at short-term follow-up; SMD -0.24, 95% CI-0.54 to 0.07, moderate quality, at intermediate-term follow-up) compared to other types of interventions. There was moderate quality evidence that CBT was better than other interventions for improving kinesiophobia at intermediate-term follow-up (SMD -0.39, 95% CI -0.69 to -0.08, I(2) = 0%). Finally, there was very low quality evidence that CBT in addition to another intervention did not differ from the other intervention alone in terms of effect on pain (SMD -0.36, 95% CI -0.73 to 0.02) and disability (SMD -0.10, 95% CI -0.56 to 0.36) at short-term follow-up.For patients with subacute NP, there was low quality evidence that CBT was better than other interventions at reducing pain at short-term follow-up (SMD -0.24, 95% CI -0.48 to 0.00), while no difference was found in terms of effect on disability (SMD -0.12, 95% CI -0.36 to 0.12) and kinesiophobia.None of the included studies reported on adverse effects. AUTHORS' CONCLUSIONS: With regard to chronic neck pain, CBT was found to be statistically significantly more effective for short-term pain reduction only when compared to no treatment, but these effects could not be considered clinically meaningful. When comparing both CBT to other types of interventions and CBT in addition to another intervention to the other intervention alone, no differences were found. For patients with subacute NP, CBT was significantly better than other types of interventions at reducing pain at short-term follow-up, while no difference was found for disability and kinesiophobia. Further research is recommended to investigate the long-term benefits and risks of CBT including for the different subgroups of subjects with NP.

Reliability of spatial-temporal gait parameters during dual-task interference in people with multiple sclerosis. A cross-sectional study.

PURPOSE: To evaluate the reliability and minimum detectable change (MDC) of spatial-temporal gait parameters in subjects with multiple sclerosis (MS) during dual tasking. METHOD: This cross-sectional study involved 25 healthy subjects (mean age 49.9 ± 15.8 years) and 25 people with MS (mean age 49.2 ± 11.5 years). Gait under motor-cognitive and motor-motor dual tasking conditions was evaluated in two sessions separated by a one-day interval using the GAITRite Walkway System. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs), standard errors of measurement (SEM), and coefficients of variation (CV). MDC scores were computed for the velocity, cadence, step and stride length, step and stride time, double support time, the % of gait cycle for single support and stance phase, and base of support. RESULTS: All of the gait parameters reported good to excellent ICCs under both conditions, with healthy subject values of >0.69 and MS subject values of >0.84. SEM values were always below 18% for both groups of subjects. The gait patterns of the people with MS were slightly more variable than those of the normal controls (CVs: 5.88-41.53% vs 2.84-30.48%). CONCLUSIONS: The assessment of quantitative gait parameters in healthy subjects and people with MS is highly reliable under both of the investigated dual tasking conditions.

Home-based functional exercises aimed at managing kinesiophobia contribute to improving disability and quality of life of patients undergoing total knee arthroplasty: a randomized controlled trial.

OBJECTIVE: To compare the improvement in disability, kinesiophobia, pain, and quality of life obtained by means of home-based functional exercises aimed at managing kinesiophobia with that obtained by giving subjects undergoing total knee arthroplasty (TKA) advice to stay active after discharge from a rehabilitation unit. DESIGN: Randomized controlled trial with 6-months' follow-up. SETTING: Patients' homes. PARTICIPANTS: Patients (N=110; 40 men; mean age, 67y) at the end of a 15-day period of in-hospital rehabilitation after undergoing primary TKA. INTERVENTIONS: In the experimental group, before returning home, the patients were asked to continue the functional exercises learned during hospitalization in twice-weekly 60-minute sessions for 6 months, and were given a book containing theoretical information about the management of kinesiophobia. In the control group, the patients were advised to stay active and gradually recover their usual activities. MAIN OUTCOME MEASURES: Repeated-measures analysis of covariance with baseline values as the covariates (P<.05) was used to assess the effect of treatment on disability, fear-avoidance beliefs, pain intensity, and quality of life. RESULTS: The analysis revealed a significant time by group interaction in all the variables in favor of the experimental group. Post hoc analysis showed that the effect of the group was statistically significant at the end of home training and follow-up. The treatment effect was clinically tangible in terms of disability and quality of life, and persisted for 6 months after the intervention ended. CONCLUSIONS: A home-based program based on functional exercises and the management of kinesiophobia was useful in changing the course of disability, fear-avoidance beliefs, pain, and the quality of life in patients with TKA.

Metodologia Psicodramatica na Educacao Preventiva da AIDS

Este trabalho relata experiencias que um grupo de quatro psicologos e dois medicos da 'Associacao de Psicodrama e Sociodrama Revolucao Creadora' vem desenvolvendo, com Sociodramas Publicos, com a comunidade de Sao Paulo (capital e interior), numa campanha educativa que pretende elucidar o tema AIDS em seus aspectos cognitivos, psiquicos, emocionais e sociais.