Evidence-informed management of chronic low back pain with functional restoration

doi:10.1016/j.spinee.2007.10.012

The Spine Journal

Volume 8, Issue 1, January–February 2008, Pages 65-69

https://doi.org/10.1016/j.spinee.2007.10.012 Get rights and content

Abstract

Editors' preface

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Section snippets

Terminology

At the outset, it should be noted that functional restoration refers not only to an intervention for chronic low back pain (CLBP), but also to a wider conceptualization of its diagnosis, management, and the challenges facing clinicians and patients dealing with this condition. Functional restoration is based on the biopsychosocial approach to CLBP which views pain and disability as a complex and dynamic interaction among physiological, psychological, and social factors that perpetuate or worsen

Mechanism of action

The purported benefit of functional restoration is that the combined effect of each intervention administered within this type of integrated program is greater than the sum of its parts. The expected benefits of functional restoration are achieved through enhanced communication between providers and by adopting a holistic approach to patient management by simultaneously addressing physical, psychological, and vocational impediments to returning to work.

Diagnostic testing required

A thorough medical history and physical

Systematic reviews

A systematic review by Guzman et al. found strong evidence that intensive interdisciplinary rehabilitation with functional restoration reduces pain and improves function in patients with CLBP significantly more than less intensive programs or usual care [18]. In addition, van Tulder et al. found strong evidence in favor of functional restoration programs, using the Cochrane Collaboration's high methodology and analysis standards [19]. Finally, a recent review in The New England Journal of

Harms

There are no undue complications, such as reinjury, because functional restoration is carefully monitored and directed by a physician and by an interdisciplinary team of health-care professionals who meet on a regular basis to discuss patient issues/problems.

Summary

The scientific literature has demonstrated the effectiveness of functional restoration for patients with CLBP in the United States, and in different countries around the world. Results have been positive in different workers' compensation and socioeconomic systems, which speaks highly for the generalizability and robustness of this approach in carefully selected patients. An important advantage of functional restoration relative to traditional unimodal medical intervention methods is that it

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Cited by (52)

Pain Intensity as a Lagging Indicator of Patient Improvement: Longitudinal Relationships With Sleep, Psychiatric Distress, and Function in Multidisciplinary Care
2021, Journal of Pain
Despite a common assumption that reductions in chronic pain intensity must precede improvements in other pain-relevant domains, there has been limited empirical inquiry into the temporal ordering of improvements in chronic pain treatment. Cross-lagged models using retrospective clinical data examined relationships between average pain intensity and symptoms of psychological distress, difficulties with sleep initiation and maintenance, and disability in 666 treatment-seeking patients with chronic pain who demonstrated improvement in pain intensity (≥1-point reduction on 0-10 numeric rating scale) over a 1-year span. Results indicated that decreased difficulties with sleep initiation, depressive and anxious symptoms, and disability predicted later improvement in pain intensity, whereas greater pain intensity predicted only later difficulties in sleep initiation and maintenance. A combined lagged model highlighted fewer baseline symptoms of post-traumatic stress disorder and lower levels of baseline disability as significant predictors of later improvements in pain. Overall, our results indicate that reductions in pain intensity may not be the first factors to change in effective chronic pain management. The current findings should be replicated using prospective studies utilizing structured approaches to maximize data capture, as well as uniform interventional approaches to permit greater inferences regarding causal and temporal aspects of the model.
This study demonstrates that pain intensity scores are not robust predictors of psychosocial outcomes longitudinally. Instead, other factors such as sleep initiation, psychological distress and disability appear to be important targets for intervention that may promote effective pain reduction.
Criteria for success after surgery for cervical radiculopathy—estimates for a substantial amount of improvement in core outcome measures
2020, Spine Journal
Defining clinically meaningful success criteria from patient-reported outcome measures (PROMs) is crucial for clinical audits, research and decision-making.
We aimed to define criteria for a successful outcome 3 and 12 months after surgery for cervical degenerative radiculopathy on recommended PROMs.
Prospective cohort study with 12 months follow-up.
Patients operated at one or two levels for cervical radiculopathy included in the Norwegian Registry for Spine Surgery (NORspine) from 2011 to 2016.
Neck disability index (NDI), Numeric Rating Scale for neck pain (NRS-NP) and arm pain (NRS-AP), health-related quality-of-life EuroQol 3L (EQ-5D), general health status (EQ-VAS).
We included 2,868 consecutive cervical degenerative radiculopathy patients operated for cervical radiculopathy in one or two levels and included in the Norwegian Registry for Spine Surgery (NORspine). External criterion to determine accuracy and optimal cut-off values for success in the PROMs was the global perceived effect scale. Success was defined as “much better” or “completely recovered.” Cut-off values were assessed by analyzing the area under the receiver operating curves for follow-up scores, mean change scores, and percentage change scores.
All PROMs showed high accuracy in defining success and nonsuccess and only minor differences were found between 3- and 12-month scores. At 12 months, the area under the receiver operating curves for follow-up scores were 0.86 to 0.91, change scores were 0.74 to 0.87, and percentage change scores were 0.74 to 0.91. Percentage scores of NDI and NRS-AP showed the best accuracy. The optimal cut-off values for each PROM showed considerable overlap across those operated due to disc herniation and spondylotic foraminal stenosis.
All PROMs, especially NDI and NRS-AP, showed good to excellent discriminative ability in distinguishing between a successful and nonsuccessful outcome after surgery due to cervical radiculopathy. Percentage change scores are recommended for use in research and clinical practice.
Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A preplanned subgroup analysis of a randomized controlled trial
2017, Spine Journal
Citation Excerpt :
The use of advice as the comparison group had its limitations. Because advice is typically administered over one to two sessions [19,20,55] and individualized functional restoration is a more intensive approach [56,57], a different number of sessions was necessary for each group to reflect clinical practice. Although the larger amount of therapist attention provided by 10 sessions of individualized functional restoration relative to two sessions of advice could potentially explain some of the effects, other low back pain and radiculopathy trials that have involved a similar imbalance in the number of treatment sessions delivered to each group have found no differences in outcomes [58–60].
Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population.
To determine the effectiveness of physical therapist-delivered individualized functional restoration as an adjunct to guideline-based advice in people with lumbar disc herniation and associated radiculopathy.
This is a preplanned subgroup analysis of a multicenter parallel group randomized controlled trial.
The study included 54 participants with clinical features of radiculopathy (6-week to 6-month duration) and imaging showing a lumbar disc herniation.
Primary outcomes were activity limitation (Oswestry Disability Index) and separate 0–10 numerical pain rating scales for leg pain and back pain. Measures were taken at baseline and at 5, 10, 26, and 52 weeks.
The participants were randomly allocated to receive either individualized functional restoration incorporating advice (10 sessions) or guideline-based advice alone (2 sessions) over a 10-week period. Treatment was administered by 11 physical therapists at private clinics in Melbourne, Australia.
Between-group differences for activity limitation favored the addition of individualized functional restoration to advice alone at 10 weeks (7.7, 95% confidence interval [CI] 0.3–15.1) and 52 weeks (8.2, 95% CI 0.7–15.6), as well as back pain at 10 weeks (1.4, 95% CI 0.2–2.7). There were no significant differences between groups for leg pain at any follow-up. Several secondary outcomes also favored individualized functional restoration over advice.
In participants with lumbar disc herniation and associated radiculopathy, an individualized functional restoration program incorporating advice led to greater reduction in activity limitation at 10- and 52-week follow-ups compared with guideline-based advice alone. Although back pain was significantly reduced at 10 weeks with individualized functional restoration, this effect was not maintained at later timepoints, and there were no significant effects on leg pain, relative to guideline-based advice.
Wishing It So Does Not Make It So! Response to a Letter to the Editor
2017, Journal of Pain
Educational self-care objectives within a functional spine restoration program. Retrospective study of 104 patients
2016, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
Mean pain score on a 10-point VAS decreased from 5.02 to 1.94 at the end of the program and was 2.5 at 6 months, therefore from moderate to mild. Our study is similar to that by Gatchel and Mayer, who showed that subjects benefiting from this type of program less frequently used analgesics [19]. In our study, more than 86% of patients were taking analgesics before the program as compared with 40% at 6 months.
Defining individual educational, or learning, targets is part of the initial educational assessment in rehabilitation programs, but no data are available on how to achieve these goals.
We aimed to evaluate whether educational objectives established with the patient as part of a functional spine restoration program integrating self-care sessions were met after the program and associated therapy outcomes.
This retrospective study involved 104 patients with chronic low-back pain who participated in a self-care rehabilitation program between 2008 and 2012. The program included both physical and educational approaches to dealing with the condition. The main evaluation criterion was achieving the educational objectives established with the patient at 6 months. Secondary criteria were a return to work, pain intensity and impact on function, satisfaction with the program and implementation of physical activity and self-rehabilitation at 6 months.
At 6 months, 55% of the established educational objectives were fully achieved and satisfaction was close to 90%. Significantly, more patients were involved in a physical activity at 6 and 12 months and self-rehabilitation exercises at 6 months as compared with at inclusion. Overall, 43.4% were working at inclusion, 64.2% at 6 months and 58.2% at 12 months (P < 0.05 compared with inclusion). Pain intensity and scores from the Quebec, Dallas and FABQ questionnaires had significantly decreased at 6 months.
For more than half of the patients in this self-care rehabilitation program, educational objectives established with the patient were achieved, with a positive effect on returning to work and both professional and physical activities at 6 and 12 months.
Facilitating surgical decisions for patients who are uncertain: A pilot surgical option process within an interdisciplinary functional restoration program
2014, Spine Journal
Citation Excerpt :
Therefore, the development of a surgical option process (SOP) associated with interdisciplinary FR was undertaken to provide a resolution to this impasse. There has been evidence supporting the use of certain FR programs to resolve chronic disability with promising long-term work and socioeconomic outcomes [1,10–19]. A comprehensive interdisciplinary rehabilitation program that uses a coordinated and goal-directed approach and has “proven successful outcomes” is recommended by some evidence-based treatment guidelines, such as ODG [1].
For chronic pain patients, recovery may be slowed by indecisiveness over optional surgery. These patients may be delayed from participating in interdisciplinary functional restoration (FR), pending resolution of the surgical decision. Uncertainty about surgery or rehabilitation leads to delayed recovery. A surgical option process (SOP) was developed to permit patients with chronic disabling occupational musculoskeletal disorders to enter FR, make a final determination halfway through treatment, and return to complete rehabilitation after surgery, if surgery was elected.
This study assessed the frequency with which an FR program can resolve an uncertain surgical option. It also assessed program completion rate and 1-year post-program outcomes for subgroups that decline surgery, request and receive surgery, or request surgery but are denied by surgeon or insurance carrier.
Retrospective study of a consecutive cohort.
A cohort of 44 consecutively treated chronic disabling occupational musculoskeletal disorder patients were admitted to an FR program and identified as candidates for a surgical procedure but were either ambivalent about undergoing surgery, had a difference of opinion by two or more surgeons, or were denied a surgical request by an insurance carrier. Patients attended half (10 full day visits) of an FR program before making their own final determination to pursue a request or decline surgery.
Patients were assessed on surgical requests and whether surgery was ultimately performed, program completion status after the surgical determination, demographic variables, and 1-year outcomes on work status, additional surgery, and other health utilization measures.
Patients became part of the SOP on program entry and were included in the study if they participated in a surgical-decision interview halfway through the program. Those who elected to decline surgery (DS) completed the program without delay, but those requesting surgery were placed on hold from the program while consultation and preauthorization steps took place. Those requesting surgery, but denied (RSD), and those undergoing surgery (US) were given the opportunity to complete FR following postoperative physical therapy or resolution of the surgical re-evaluation process.
There were 32 DS patients (73%), indicating that a large majority of patients declined the surgery that was still being considered when offered participation in the SOP. Of the 12 patients wanting a surgery, there were four US patients who received surgery previously denied (9% of cohort), and eight RSD patients (18% of cohort). Patients from the DS group completed the FR program at an 88% rate, as did 75% of US patients. However, despite an opportunity to re-enter and complete rehab, only 50% of RSD patients completed the FR option. Overall, patients who persistently sought surgery, contrary to the recommendations of a surgeon, had poorer outcomes. These 1-year post-FR outcomes included lower return-to-work and work retention rates, with higher rates of treatment seeking from new providers (resulting in higher rates of post-discharge surgery) and higher rates of recurrent injury claims after work return.
A SOP tied to participation in an interdisciplinary FR program resolves uncertainty regarding surgical options in a high proportion of cases, resulting in a large majority declining surgery and completing the FR program. Timely surgery is also promoted decisively when needed. Findings suggest that patients who persistently seek surgery, contrary to the recommendations of a surgeon, frequently fail to complete FR and have poorer outcomes overall.

View all citing articles on Scopus

: FDA device/drug status: not applicable.

: This research was supported in part by grants (R.J.G) from National Institutes of Health (grant numbers 1K05 MH071892 and 3R01 MH 045462) and the Department of Defense (grant number DAMD 17-03-1-0055), which are federal/state agencies.

: Nothing of value received from a commercial entity related to this manuscript.

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Intervention Review ArticleEvidence-informed management of chronic low back pain with functional restoration

Abstract

Editors' preface

Section snippets

Terminology

Mechanism of action

Diagnostic testing required

Systematic reviews

Harms

Summary

J Pain

Arch Phys Med Rehabil

Best Pract Res Clin Rheumatol

Pain

Comorbidity of chronic pain and mental health disorders: the biopsychosocial perspective

Am Psychol

Biopsychosocial perspective on chronic pain

Functional restoration for spinal disorders: the sports medicine approach

A review of 1985 Volvo Award winner in clinical science: objective assessment of spine function following industrial injury: a prospective study with comparison group and 1-year follow-up

Spine

Interdisciplinary programs: chronic pain management

Occupational musculoskeletal disorders: function, outcomes and evidence

Tertiary nonoperative interdisciplinary programs: the functional restoration variant of the outpatient chronic pain management program

Occupational musculoskeletal disorders: function, outcomes, and evidence

Psychosocial factors and pain: revolution and evolution

Occupational musculoskeletal pain and disability

“Carving-out” services from multidisciplinary chronic pain management programs: negative impact on therapeutic efficacy. A guidebook for multidisciplinary program development

Evidence-based review of the efficacy of cognitive behavioral therapy for the treatment of chronic low back pain

Spine J

The negative impact on an interdisciplinary pain management program of insurance “treatment carve out” practices

J Workers' Compensation

Effectiveness of in-patient rehabilitation for sub-chronic and chronic low back pain by an integrative group treatment program (Swiss Multicentre Study)

Scand J Rehabil Med

A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies

Anesth Analg

Intervention Review Article
Evidence-informed management of chronic low back pain with functional restoration