Participants
This prospective study’s cohort of 201 patients was enrolled at the University Hospitals of Geneva’s MBR program between 2006 and 2015. All eligible and willing patients attending either the Rheumatology or Rehabilitation clinics were invited to participate. Program inclusion criteria required French-speaking patients aged from 18 to 65 years old and suffering from non-specific LBP (with or without radiating leg pain) despite standard medical and exercise-based physical care prescribed by their general practitioner. Those in paid employment also had to be on sick leave. Exceptions were allowed in cases involving repetitive sick leave over the previous year or when patients presented with a high level of disability associated with significant psychosocial issues. Exclusion criteria were specific LBP due to infection, a tumor, spondyloarthropathy, radicular leg pain due to disc herniation, and neurogenic claudication related to spinal stenosis. Patients suffering from medical comorbidities which might interfere with or prohibit their participation (e.g., cardiac or pulmonary failure, severe mood disorder, disabling knee osteoarthritis) were also excluded, as were those with neck or diffuse chronic pain syndrome. Patients receiving disability benefit payments were likewise excluded. In Switzerland, sick leave can last for up to 720 days before a disability pension is allocated. All physical therapies outside the program were stopped for its duration as patients’ health insurance policies would not have reimbursed them. The relevant rheumatology or rehabilitation physicians adjusted pain medication on a case by case basis before program commencement.
Treatment setting
The Geneva MBR program for chronic LBP was designed in 2005 to restore individuals’ musculoskeletal function. It includes significant cognitive–behavioral components and work-related goals and outcomes. Because of organizational constraints, the program only runs five times per year. A multidisciplinary team (a rheumatologist, a rehabilitation physician, a pain specialist, a psychiatrist, physiotherapists, occupational therapists, and a psychologist) followed small groups of four to six patients through the high-intensity, four-week, 100-h outpatient program, as described in detail in earlier publications [
17,
18].
In summary, the program started with a one-day individual evaluation involving physical and psychological tests, and a clinical tool, based on a set of pictures, was used to gather important information with which to set meaningful, individual, therapeutic goals [
19]. The tool identified patients’ priorities in their daily lives and their perceived degree of apprehension about performing those activities. This evaluation made it possible to negotiate personalized, realistic, meaningful objectives, which were both measurable and achievable in the care process. The goal-setting process was conducted during individual sessions supervised by the psychologist who had conducted the psychological tests. The psychologist did not provide any therapy during the program. The entire clinical evaluation and the goal-setting process were completed by the end of day two.
All sessions were group sessions, however, the physiotherapist had a panel of exercises to choose from and thus tailored the nature and intensity of physical exercises to each patient’s individual evaluation, physical capacities, psychosocial impairments, expectations, and priorities. Intensity was also adapted with regards to patients’ fear-avoidance beliefs and observed behaviors. Patients with a high level of fear-avoidance were initially prescribed lower objectives, but these were gradually raised when successfully reached. There were five types of group treatment sessions (Additional file
1). Type one involved 52 physical treatment sessions supervised by the physiotherapist, including cardiorespiratory fitness, muscular strength, muscular flexibility, stabilization exercises, relaxation, proprioception, and water aerobics. Type two involved 10 h of occupational therapy with an emphasis on physically difficult professional and daily life situations. These sessions addressed general needs (e.g., carrying, lifting, sitting, housekeeping tasks), individual patients’ goals for more specific tasks and, depending on the initial evaluation, additional workplace adaptations discussed individually with an occupational therapist. Most situations were dealt with during discussion sessions at the hospital but, in selected situations, on-site, workplace visits took place to improve the evaluation. Adaptations to workplaces were proposed according to specific needs; however, because of administrative constraints, some workplace interventions occurred after the program had ended. Thirdly, the rheumatologist or the rehabilitation physician led six patient-education sessions based on the non-injury [
20] and biopsychosocial models. Fourthly, a weekly, one-hour support group discussion was led by a psychiatrist. Fifthly, 20 h of self-management exercises were scattered through the second half of the program.
The program aimed to increase muscle activity progressively and to help patients overcome their fear of movement whenever fear-avoidance beliefs were present. Patients’ kinesiophobia was estimated during their initial physical evaluations by observing their behavior or from their scores on the Tampa Scale for Kinesiophobia. As part of the program, patients were asked to develop personal booklets of illustrated, annotated exercises and techniques appropriate to their own condition. Throughout the program, they were encouraged to work out how they could integrate physical exercises into their daily life and possibly organize regular sporting activities. Each patient was explicitly expected to come to the last session with a detailed plan describing the what, when, where, and how of the exercise and sporting activities they would carry out over the following weeks, based on their experiences during the program. The MBR program was designed as an integrated program involving direct communication between team members and weekly multidisciplinary clinical meetings. Therapists shared objective and subjective clinical impressions during these meetings, also attended by the psychologist, and exercise requirements and individual goals were adapted to each patient’s progress.
Patients were informed that a multidisciplinary 3-h refresher course would be organized 5–6 months after the end of the program and that a postal survey would be organized at 18 months using the same patient-reported outcomes. The 6-month session’s main goal was to reinforce regular exercise and sporting activities. The program did not monitor patients’ adherence to their home-based programs, however, the refresher session motivated patients to continue following them and it repeated and reinforced messages about mobility, exercises, risks associated with fear-avoidance beliefs and behaviors, and the importance of goal setting for further improvement. An occupational therapist and a physiotherapist provided additional information according to individual needs. The occupational therapist helped facilitate returns to work during the months after the program, if necessary and possible, by promoting progressive returns to work with lighter duties. The planned postal survey was conducted at 18 months. In the absence of a response, a second questionnaire was sent, followed, if needed, by a telephone call.
Outcome measures
At study entry, patients were categorized into one of four work statuses (working full-time, on sick leave, unemployed, or receiving social welfare payments) and this was recorded at every subsequent time-point to create a binary variable (had or had not recovered the capability to work). Overall capability to work was computed from patient-reported outcomes. The recovery of work capability was defined as either partial or full-time employment, being incorporated into an unemployment support program, and being on sick leave for a reason that had nothing to do with spinal pain.
The
Core Outcome Measures Index (COMI) [
21,
22] is a multidimensional, self-administered questionnaire that first assesses two pain symptoms (back and leg pain) on a 0–10 numerical rating scale. Five additional items assess the level of function, symptom-specific wellbeing, generic QoL, and work and social disability (averaged to form one disability score) over the previous month. These five items are rated on 5-point Likert scales with scores ranging from 0 (excellent condition) to 4 (worst condition). An overall score from 0 (best health status) to 10 (worst health status) can be calculated by averaging the subscales.
The
Oswestry Disability Index (ODI) [
23,
24] is the most commonly used, condition-specific outcome measure used in LBP management. Its 10 items, self-rated from 0 to 5, measure how back or leg pain affect the patient’s ability to manage everyday life. The sum of the 10 item-scores is multiplied by two so that the final score ranges from 0 to 100. A change of at least 10 points in the final range has been shown to be clinically meaningful.
The
Tampa Scale for Kinesiophobia (TSK), developed by Miller et al. [
25], is a self-administered measure of fear of movement. Kinesiophobia is defined as an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury. Seventeen items are rated on 4-point Likert scales ranging from 1 (strongly disagree) to 4 (strongly agree). The total score thus ranges from 17 to 68, with higher scores indicating higher degrees of kinesiophobia.
The
Hospital Anxiety and Depression Scale (HADS) [
26] is a reliable, self-administered scale for detecting states of depression and anxiety in general hospital practice settings. It is composed of 14 items, each rated on a 4-point (0–3) response scale, with total scores ranging from 0 to 21 for anxiety and 0–21 for depression. A score of 8–10 is suggestive of the respective mood’s presence, and a score of 11 or higher indicates the probable presence of the mood disorder.
The
Medical Outcome Study Short-Form Health Survey 12-items (MOS SF-12) [
27‐
29]. Derived from the well-known SF-36, this generic, self-administered measure of subjective health-related QoL, looks at two distinct overall physical and mental health concepts known as the Physical Component Summary (PCS) and the Mental Component Summary (MCS). MOS SF-12 has a mean score of 50 and a standard deviation of 10: the higher the score, the better the QoL. It has demonstrated good psychometric qualities among LBP patients [
30].
Study design
Patients in this prospective cohort study completed all the questionnaire instruments on their admission to the Geneva MBR program, at the end of the 4-week program, and at the 6- and 18-month, one-day refresher courses. Failure to respond resulted in a second postal questionnaire being sent. Furthermore, at the 18-month follow-up, patients were telephoned to increase the response rate. All investigations were part of the treatment program’s routine clinical assessment. The study was conducted in accordance with the principals of the Declaration of Helsinki (2000 revision) and was approved by the local ethics committee.