<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercises—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series will summarize a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on the effectiveness of multidisciplinary biopsychosocial rehabilitation for nonspecific chronic low back pain. Can multidisciplinary biopsychosocial rehabilitation help this patient with chronic low back pain?
Low back pain (LBP) is an important public health problem worldwide.2 The economic burden associated with this condition is enormous in most countries, and it is the leading cause of years lived with disability.3 Although patients with acute LBP typically have a favorable prognosis, approximately 40% will develop chronic LBP, defined as pain lasting for 12 weeks or longer.4 Chronic LBP is responsible for the majority of costs of LBP.5
Increasingly, chronic LBP is conceptualized within a biopsychosocial model, and accordingly interventions that target the biological, psychological, and social contributors to the condition have become popular.6 One treatment approach based on the biopsychosocial model is multidisciplinary biopsychosocial rehabilitation, where patients receive treatment from a range of health professionals with different skills to reduce symptoms, activity limitation, and participation restriction. The components of this treatment may include education, exercise, psychological therapies, occupational interventions, and review of pain medicines. Kamper et al7 recently performed a Cochrane systematic review to examine the evidence on the effectiveness of multidisciplinary biopsychosocial rehabilitation for patients with chronic LBP. The searches were conducted up to March 2014.
Take-Home Message
Forty-one trials with a total of 6,858 participants were included in the Cochrane review (Tab. 1). In this review, multidisciplinary biopsychosocial rehabilitation was compared with usual care (mainly consisting of medical management, pain control, and education [16 trials]), physical treatment (ie, exercise program or physical therapy treatment [19 trials]), surgery (ie, spinal stabilization surgery or disk replacement with artificial disk [2 trials]), and waiting list (4 trials). The sample size of the included trials varied from 20 to 542 participants. The following outcomes were evaluated: pain, disability or function, work-related outcomes, global improvement, health care service utilization, quality of life, psychological function, and adverse events. The overall quality of evidence was assessed using the GRADE approach, which describes the certainty in the estimate of treatment effect and ranges from high certainty to very low certainty in the evidence.
Cochrane Review7 Resultsa
When multidisciplinary biopsychosocial rehabilitation was compared with usual care, there was low- to moderate-quality evidence that multidisciplinary biopsychosocial rehabilitation decreases pain and disability with mostly small effect sizes but has no effect on work outcomes. When compared with physical treatment, multidisciplinary biopsychosocial rehabilitation showed low- to moderate-quality evidence of a small effect on pain at short-term and intermediate-term, disability at short-term and long-term, and work outcomes at medium-term and long-term. When multidisciplinary biopsychosocial rehabilitation was compared with surgery, there was low-quality evidence that there is no significant difference for pain, disability, and work outcomes. Finally, the comparison between multidisciplinary biopsychosocial rehabilitation and waiting-list control provided very low-quality evidence of a moderate effect size on pain and low-quality evidence of a small effect size on disability at short-term.
This Cochrane review also had some limitations. First, as there is no established definition of multidisciplinary biopsychosocial rehabilitation, we have chosen a definition based on the authors' interpretation of the biopsychosocial model, and the use of a different definition may result in different studies being included. Second, there were several differences in the characteristics of the intervention (ie, number of sessions, balance of the multidisciplinary biopsychosocial rehabilitation intervention, care providers) among the included trials. Third, it is unclear what exactly usual care means, as there is no standard definition for this term. Lastly, none of the trials blinded clinicians, patients, or assessors, so it is likely that the trials overestimated effects of this therapy.
Case #27: Applying Evidence to a Patient With Chronic Back Pain
Can multidisciplinary rehabilitation help this patient?
“Mr Costa” is a 45-year-old dentist who has had LBP for approximately 4 years. He used to manage his chronic LBP with a routine of physical activity (running and weight training) 2 times per week; however, in the last 6 months, he increased his working hours and ceased physical activities. He reports that the pain has become more severe and frequent in the last 3 months, and the pain is now interfering with his work. In the last month, he had to take 7 days of sick leave due to his LBP. He also reports problems with sleep, as he wakes up at night due to pain and cannot find a comfortable position to relieve the pain. He used to take analgesics and anti-inflammatories for temporary pain relief. He is upset and disappointed because of his condition. He is also feeling anxious most of the time because he cannot work, as he would like to do.
He reports right-side lower back pain rated as 7 out of 10, but he has no leg symptoms. He completed the Roland-Morris Disability Questionnaire (RMDQ), which measures the disability associated with LBP, with a total score ranging from 0 (no disability) to 24 (high disability).9 He also completed the Hospital Anxiety and Depression Scale (HADS) and the Tampa Scale for Kinesiophobia (TSK) to measure fear of movement. The HADS is a 14-item scale with 7 items related to anxiety and 7 items related to depression, in which each item is scored from 0 to 3, with a total score ranging from 0 (no depression or anxiety) to 21 for either anxiety or depression.10 The TSK is a 17-item questionnaire with Likert-type scales ranging from 1 (“strongly disagree”) to 4 (“strongly agree”), in which the final score ranges from 17 to 68 points, with higher scores representing higher degrees of kinesiophobia.11 The RMDQ score was 12/24, the TSK score was 22/68, and the HADS score was 5/21 for depression and 8/21 for anxiety. Mr Costa's disability level is typical for people seeking care for chronic LBP.12–14 The TSK score is lower than the reference values for patients with chronic pain and does not appear to be related to higher levels of kinesiophobia.12 The score for depression appears within the normal range expected in the general population, whereas the score for anxiety is slightly higher than for the general population and would represent mild signs of anxiety.15,16
In the physical examination, the range of motion (ROM) of the lumbar spine (extension, flexion, and rotation) was tested using an inclinometer. The ROM was within the normative values for flexion (60°) and right rotation (25°), but it was limited for left rotation (15°) and extension (15°). Mr Costa also reported pain during the extension ROM evaluation. He demonstrated reduced strength of the abdominal muscles (grade 4) on manual muscle strength testing.17 Trunk endurance was assessed with the Sorensen test18 for the extensors and with an abdominal endurance test (Ito test),19 and, for both tests, his performance was considered below average (holding position less than 60 seconds for both tests). His clinician also evaluated physical performance with the 5-minute walking test, the repeated sit-to-stand test, and the loaded forward reach test.20 Mr Costa's distance covered during the 5-minute walking test was 300 m, the average time to complete 5 sit-to-stand movements was 20 seconds, and the distance reached in the loaded forward reach test was 44 cm. The performance of Mr Costa was considered low for these 3 physical tests.20 The performance and endurance measures used are presented in the Appendix.
How did the results of the Cochrane review apply to Mr Costa?
Following Mr Costa's evaluation, his physical therapist considered whether multidisciplinary rehabilitation would be a good treatment choice for him. The PICO (Patient-Intervention-Comparison-Outcome) question he considered was: In a middle-aged man with chronic LBP, will multidisciplinary rehabilitation (as compared with other treatments) be beneficial for reducing pain and disability? The Cochrane review by Kamper et al7 was identified and provided useful information for this patient.
Patient.
The Cochrane review7 included typically middle-aged participants (average age between 40 and 45 years) with chronic nonspecific LBP and with symptoms persisting for more than 1 year, on average, like Mr Costa.
Intervention.
There was a great variety in the elements of the multidisciplinary biopsychosocial rehabilitation presented in the review by Kamper et al,7 and the elements that seemed most relevant to Mr Costa were: a graded exercise program, education, workplace visit and ergonomic counseling, medication review, and cognitive-behavioral therapy. As there was no clinic nearby that offered a full multidisciplinary program, the physical therapist worked with the patient's general practitioner (GP) and a clinical psychologist to provide the components of the intervention. The physical therapist, psychologist, and GP had fortnightly teleconference meetings to evaluate the treatment of Mr Costa. The GP who reviewed Mr Costa's medication considered the intervention adequate for the current symptoms and treatment goals.
The physical therapy intervention comprised a combination of strength training and flexibility for trunk muscles, aerobic exercise, ergonomic intervention, and education. The strength training included specific exercises for the trunk muscles aiming to improve strength and endurance. He performed 3 sets of 10 to 15 repetitions for each strength exercise, with up to 60 seconds of rest between sets. The flexibility exercises comprised static stretching for trunk muscles held for 10 to 30 seconds to the point of tightness or slight discomfort repeated 2 to 4 times, accumulating 60 seconds per stretch. The aerobic exercise began with 20 to 30 minutes of brisk walking 5 days per week at an intensity level between fairly light and somewhat hard on the Borg Scale,21 progressing to 15 to 20 minutes running at an intensity level between somewhat hard and hard. The goal was at least 150 minutes of moderate-intensity exercise per week.22 The ergonomic intervention included simulated work tasks focused on Mr Costa's posture during work and workplace visits to advise about ergonomics.
At the beginning of treatment, the physical therapist provided advice (eg, workplace position, self-management of pain); an educational booklet titled The Back Book,23 which includes information on how the patient may deal with the pain, restore movement, prevent disability, stay active, and lead an optimal life; and a home exercise booklet, including exercises (strength, stretching, and relaxation) to perform during work breaks. During the physical therapy sessions, the physical therapist taught the patient how to use pacing to increase his activity levels and discussed self-reinforcement as goals were met by Mr Costa. The physical therapy sessions were performed 2 times per week (1-hour session) for 10 weeks. Mr Costa also had a home exercise program. The psychologist conducted sessions of cognitive-behavioral therapy, which were divided into a theoretical introduction to the topic (ie, etiology and physiology of pain and stress), group discussion about personal experiences, and exercises using techniques for pain management (progressive muscle relaxation or cognitive reappraisal of pain and stress, and stretching). The sessions also included strategies to manage anxiety and stress. The therapy consisted of 10 sessions once a week divided between 8 group sessions (up to 8 patients) lasting 90 minutes and 2 individual sessions of 50 minutes. The total duration of the cognitive-behavioral therapy was the same as the physical therapy treatment (10 weeks).
Comparison.
The results of the systematic review suggest a moderate quality of evidence that multidisciplinary biopsychosocial rehabilitation is better than usual care (medical management, pain control, and education) and solely physical treatment (ie, exercise program or physical therapy treatments) for reducing pain and disability. Thus, the biopsychosocial model was used to treat Mr Costa, and the multidisciplinary team was led by the physical therapist and included the patient's GP and psychologist.
Outcome.
Mr Costa's first goal was to reduce pain intensity and improve work tolerance. The review suggests that multidisciplinary biopsychosocial rehabilitation reduces pain intensity and disability and improves work outcomes. A small or no effect was seen for the other outcomes (ie, depression, anxiety, fear avoidance, catastrophizing).
How well do the outcomes of the intervention provided to the patient match those suggested in the review?
After 10 weeks of the multidisciplinary biopsychosocial program (Tab. 2), Mr Costa experienced pain reduction of 3 points (4/10), with no leg symptoms and disability improvement of 5 points. The HADS score for anxiety decreased 3 points and the TSK score decreased 2 points. The HADS score for depression remained the same. The changes in pain and disability were greater than the minimal clinically important difference of each scale.24,25 Anxiety improved by 3 points, which can be considered as a meaningful change (more than 10% of improvement), but fear avoidance and depression did not change significantly. Mr Costa also reported that he had not taken any sick leave from work in the previous month and had been sleeping better, with fewer disruptions resulting from his LBP. The clinical examination by the end of the treatment showed that Mr Costa improved his ROM, strength, and endurance level and all physical performance tests. He is adapting his schedule to include regular running training 3 times per week (20–30 minutes) and resistance exercise 2 times per week in a gym. He also reports that he feels more confident to work and to deal with his LBP.
Self-Reported Measures Before and After the Interventiona
Can you apply the results of the review to your own patient?
The findings of the Cochrane review by Kamper et al7 apply well to Mr Costa. Although he had physical deficits that would be addressed by physical therapy alone, he also had psychosocial problems related to his LBP that would fit well to a multidisciplinary biopsychosocial rehabilitation program. Mr Costa is not an atypical patient seen by physical therapists; he is a middle-aged man with chronic symptoms that were interfering in his work and social life. Multidisciplinary biopsychosocial rehabilitation will probably help patients with chronic LBP who have physical and psychosocial deficits to improve their symptoms.
What can be advised based on the results of this systematic review?
The evidence available in the systematic review7 demonstrates that the multidisciplinary biopsychosocial rehabilitation program can be effective in treating patients with chronic LBP. The proposed intervention program can lead to a reduction of pain and disability and decreased work loss.
Although multidisciplinary biopsychosocial rehabilitation had not been previously defined and variations may exist in the applicability of the intervention, programs that follow the biopsychosocial conceptualization of chronic pain and include a combination of therapies delivered by clinicians with different backgrounds appear to be effective for chronic LBP.
Appendix.
Description of the Performance Tests
Footnotes
Mr Saragiotto and Professor Maher provided concept/idea/project design. All authors provided writing. Mr de Almeida provided data collection and data analysis. Ms Yamato and Professor Maher provided consultation (including review of manuscript before submission).
- Received June 23, 2015.
- Accepted November 22, 2015.
- © 2016 American Physical Therapy Association
References
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