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Research Reports |
JJ Godges, PT, DPT, OCS, is Coordinator, Clinical Education and Practice, Optimum Care Providers, 200 Mantua Rd, Pacific Palisades, CA 90272 (USA)
MA Anger, PT, DPTSc, is Occupational Health Physical Therapist, US Healthworks Medical Group, Ontario, Calif
G Zimmerman, PhD, is Associate Dean, Research, School of Applied Health Professions, Loma Linda University, Loma Linda, Calif
A Delitto, PT, PhD, FAPTA, is Professor and Chair, Department of Physical Therapy, and Director of Research, Comprehensive Spine Center, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pa
Address all correspondence to Dr Godges at: jgodges{at}ptholdings.com
Submitted April 10, 2005;
Accepted October 2, 2007
 | Abstract |
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Subjects: Thirty-four people who were unable to return to work following a work-related episode of low back pain and who exhibited fear-avoidance beliefs participated in this study.
Methods: Participants who scored 50 points or higher on the Fear-Avoidance Beliefs Questionnaire were alternately assigned to an education group or a comparison group. Both groups received conventional physical therapy intervention. Participants in the education group were given education and counseling on pain management tactics and the value of physical activity and exercise. The effectiveness of the interventions was measured by the number of days before people returned to work without restrictions.
Results: All participants in the education group returned to regular work duties within 45 days. One third of the participants in the comparison group remained off work at 45 days. There was a statistically significant difference between the groups with regard to the number of days before returning to work.
Discussion and Conclusion: Education and counseling regarding pain management, physical activity, and exercise can reduce the number of days off work in people with fear-avoidance beliefs and acute low back pain.
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
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In people with acute, work-related LBP, the individual's beliefs about his or her ability to return to work were most predictive of who would be off work 4 weeks after the onset of an episode of acute LBP.7,8 The early identification of people at risk of not being able to return to work following an episode of LBP may assist in the development of intervention strategies for preventing the transition of acute LBP into a chronic condition and the associated work-related disability.7–11 Fear-avoidance education and exercise intervention strategies have decreased fear-avoidance beliefs in people with LBP,10–13 and cognitive-behavioral group interventions9 and educational pamphlets14 have reduced long-term absences due to illness in people with spinal pain9 and LBP.14
An approach discussed in a case report by George and associates11 used repeated reinforcement of exercises and pain management strategies described in an educational pamphlet, The Back Book.15 This approach resulted in a reduction of fear-avoidance beliefs in a patient with acute LBP and fear-avoidance beliefs.11 The key principles described in The Back Book are for people to acknowledge that (1) LBP does not suggest the presence of a serious disease; (2) the spine is strong, and pain does not necessarily mean that the spine is damaged; (3) lasting pain relief depends on what people do and not on medical treatments; (4) activity is essential for restoring normal function and fitness; and (5) positive attitudes and coping skills are helpful.15 The physical therapy approach described by George and associates11 in this case report differed from previous approaches described in the literature in that the therapist-patient interaction in this case report repeatedly reinforced the pain management information contained in The Back Book. George and associates11 contended that this physical therapy approach has the potential to reduce fear-avoidance beliefs and disability in people with acute LBP and fear-avoidance beliefs. In previous studies, intervention strategies designed to reduce fear-avoidance beliefs in people with acute LBP10–13 focused on the effectiveness of the intervention strategies in reducing fear-avoidance beliefs (as measured by the Fear-Avoidance Beliefs Questionnaire [FABQ]) or in reducing perceived disability (eg, Roland Disability Questionnaire).
In occupational health physical therapy, the ultimate goal of any intervention strategy is to make it possible for people to return to work. The purpose of this study was to determine whether a physical therapy intervention strategy including repeated, individualized education and counseling would be effective in decreasing the number of days off work in people with fear-avoidance beliefs and acute LBP. The focus of the education and counseling provided by the physical therapist for the people in this study was on pain management tactics as well as the value of physical activity and exercise. The specific content of the education and counseling provided by the physical therapist was adapted to address the inquiries and concerns of each study subject.
| Method |
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People were excluded from this study if they: (1) had a medical diagnosis other than those listed in the inclusion criteria, such as spondylolisthesis, spinal stenosis, ankylosing spondylitis, vertebral fractures, or peripheral neuropathies; (2) were awaiting back surgery or had undergone back surgery within the last year; or (3) had a diagnosis of a lumbar disk disorder, herniated nucleus pulposus, or an intervertebral disk bulge of greater than 3 mm. The rationale for the exclusion criteria was our hypothesis that a diagnosis suggesting to an individual that he or she might have a serious pathology, whether it was serious or not, would be a confounding variable, because the individual might believe that this diagnosed tissue pathology would limit his or her ability to return to work.
Of the 57 consecutive subjects who met the 4 inclusion criteria, 55 agreed to participate in this study. After signing a consent form and answering the FABQ, 36 subjects met all of the inclusion criteria. The 36 subjects were alternately divided into 2 groups: an education group (15 men and 3 women) and a comparison group (16 men and 2 women). Because of a later diagnosis of herniated nucleus pulposus, 2 of the men in the education group were excluded from the study after physical therapy intervention was initiated.
FABQ
The FABQ is a 16-item measure of individual beliefs about whether physical activity and work should be avoided.16 This questionnaire has 2 subscales: general physical activity and work. Items are answered on a scale from "completely agree" to "completely disagree" and include statements such as "physical activity might harm my back" and "my work makes or would make my back worse." Although the FABQ contains 16 items, typically only 4 items load on the physical activity subscale and only 7 items load on the work subscale. The scores on all 16 items of the FABQ are not typically used to screen people for fear-avoidance beliefs. However, we hypothesized that the sum of the scores on all 16 items of the FABQ would be useful in identifying individuals who might benefit from education and counseling strategies designed to help them return to their previous job following a work-related low back injury. When the FABQ is used in this manner, the highest possible score is 96. We chose a score of 50 or higher in an attempt to create a homogeneous group of people with high levels of fear-avoidance beliefs. Although there is no evidence for the use of a cutoff score of 50, we hypothesized that a score of 50, which is slightly above the midpoint score of 48, would indicate that an individual was above the norm with regard to fear-avoidance beliefs. Data collection was initiated prior to publication of data on the effectiveness of FABQ work subscale scores of greater than 34 in predicting disability and in predicting work absence at 28 days in people with acute LBP.8
Procedure
All subjects had been referred for physical therapy intervention and had completed their initial physical therapy evaluations within 5 days of the injury that had produced the work-related LBP and associated inability to return to work. The occupational health physicians who referred the subjects for physical therapy intervention did not order diagnostic imaging examinations for subjects with acute, work-related LBP unless the subjects had symptoms suggesting a serious medical pathology. Upon completion of the initial physical therapy evaluations, subjects who satisfied the inclusion and exclusion criteria were asked to participate in this study and signed a consent form approved by the Loma Linda University Institutional Review Board. The FABQ then was administered. Consecutive subjects who had FABQ scores of 50 or higher were alternately assigned to the education group or the comparison group.
Subjects in both groups received a physical examination to determine physical impairments and physical therapy interventions designed to normalize impairments from pain, trunk and hip flexibility and strength (force-generating capacity) deficits, and motor control deficits. Subjects with pain-related impairments received physical agents and electrical stimulation intended to reduce pain. Subjects with trunk and hip flexibility deficits (eg, limited flexibility of the lumbar extensor, hip flexor, or hip extensor or hamstring muscles and fascia) received stretching to restore normal muscle flexibility. Subjects who exhibited trunk and hip muscle strength deficits (eg, less than normal strength of the trunk flexor/abdominal, trunk extensor, hip extensor, or hip abductor muscles) received strengthening exercises to restore normal muscle strength. Subjects who were observed to exhibit movement coordination deficits in their work-related tasks (eg, driving, keyboard work, lifting, or operating tools or machines) received training in proper ergonomics for their common work-related tasks. The occupations of the subjects in this study, as described by employers on workers’ compensation medical care requests, are provided in Table 1.
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An educational pamphlet that provides descriptions of commonly used therapeutic exercises and commonly taught ergonomic principles was given to all subjects in both groups. All physical therapy interventions for both groups were provided by the same physical therapist (MAA). Thus, this therapist provided education for both groups but did not intentionally initiate a discussion of pain management tactics or expound on the value of physical activity with the comparison group. However, if a subject in the comparison group initiated a discussion related to pain management or the value of physical activity, the therapist responded appropriately in a positive manner but did not enter into an extensive discussion on the issues of pain and movement as she did with subjects in the education group.
Subjects in the education group were given the educational booklet, Back Pain: How to Control a Nagging Backache,17 and were instructed to read the booklet during their initial physical therapy visit. We chose this educational booklet because it: (1) was readily available to physical therapists in the United States, (2) was inexpensive, (3) addressed pain management mechanisms, and (4) promotes a return to normal activity. However, there is no evidence in the literature to support the use of Back Pain: How to Control a Nagging Backache.17 The educational content of this booklet was developed in response to the awareness that biopsychosocial models can, at times, provide a better understanding of LBP and disability and that psychological issues may be as important as physical management in preventing chronicity.18,19 The titles of the educational content in this booklet are as follows:
The physical therapist discussed the booklet with subjects in the education group at the initial evaluation and during each subsequent treatment session. Three structured inquiries were used to initiate discussion and reinforce the information in the booklet. These inquiries were:
During each physical therapy session, in addition to providing the impairment-based interventions previously described, the physical therapist asked the subjects whether they were trying to stay active and cope with their LBP. On the basis of the subjects’ responses, the therapist discussed other, related topics from Back Pain: How to Control a Nagging Backache.17 These topics included:
The physical therapist who provided the interventions in this study had earned master's and doctoral degrees in physical therapy that included the following graduate-level course work related to education and counseling: psychology of physical disability, clinical psychiatry, dynamics of learning and teaching, health communications/counseling of patients, behavioral modification and personal change, and educational psychology for health care professionals. The method used in this study was designed by a physical therapist (JJG) who had earned a postgraduate degree (MA) in counseling psychology.
As required by the workers’ compensation regulatory statures in the state of California, all subjects in both groups were regularly reevaluated by their occupational health physicians. In addition, all subjects received continual review of their progress by workers’ compensation nurse case managers. The follow-up reevaluations by the occupational health physicians typically occurred on a weekly basis for all subjects. All of the occupational health physicians who were evaluating and reevaluating subjects in this study were unaware of whether the subjects met the inclusion criteria for this study. If, in the opinion of an occupational health physician, a subject's presentation or lack of progress with intervention measures required additional consultation regarding the low back symptoms, the subject was referred to an orthopedic surgeon, who commonly requested imaging and electrodiagnostic tests. Subjects with negative results on these diagnostic tests remained in the study. Subjects with positive findings on these diagnostic tests that resulted in a medical diagnosis listed in the exclusion criteria were excluded from the study.
The effectiveness of the physical therapy interventions with individualized education and counseling on pain management tactics and on the value of physical activity and exercise was measured by the number of days required to return to regular work duties from the date of the initial low back injury, as determined by the subject's occupational health physician and as documented in the subject's workers’ compensation claim. Regular work duties were defined as the ability to perform the same job duties and tasks that the subject was able to perform prior to the injury that caused this current episode of LBP and associated work-related disability. The subject's occupational health physician was unaware of whether the subject was included in the study. The time elapsed from the date of the initial injury to a return to regular work duties was evaluated for both groups by use of independent t tests. Ninety days was used for those who did not return to regular work duties after 6 months because the likelihood of returning to work following such an extended work absence diminishes3 and because the investigators did not want outliers to affect the statistical analysis. The proportions of subjects in the education group who returned to regular work duties within 28 days, 45 days, and 90 days following the initial injury were compared with those of subjects in the comparison group by use of chi-square tests.
| Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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There was no significant difference in the distribution of occupations between the groups, as evaluated with a chi-square test for homogeneity (P=.41). The number of days from the date of the initial injury to the subject's return to regular work duties was significantly different between the groups (P=.03) (Tab. 3).
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The FABQ scores and the number of days before the subjects returned to work were analyzed for correlations. An FABQ total score of 90 days was used for the 3 subjects in the comparison group who had returned to work by 100 days, 110 days, and over 180 days. This score was used to provide a conservative estimate of the correlations. The FABQ total score was positively correlated with the FABQ physical activity subscale score (r=.40, P=.02), the FABQ work subscale score (r=.83, P<.001), and the number of days required to return to work (r=.40, P=.02). A regression analysis with the number of days required to return to work as the dependent variable determined that 15.7% of the variability was explained by the FABQ total score and that an additional 14.8% of the variability was explained by group assignment. The regression coefficient (slope of the line) indicated that subjects in the comparison group returned to work an average of 18.6 days later than subjects in the education group (Tab. 4).
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| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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The only difference in the interventions between the 2 groups was the additional education and one-on-one counseling related to pain management and exercise promotion (eg, LBP rarely means that there has been serious injury to the back, pain recurs with inactivity, inactivity causes weak or stiff muscles that are more likely to be reinjured, and activity benefits overall health and well-being) that the subjects in the education group received. The education and counseling that were provided to the subjects in the education group seemed to reduce their fear of activity, enable them to tolerate trunk strengthening and flexibility exercises and, most importantly, facilitate their return to work.
The following qualitative observations were made by the physical therapist who provided interventions to both the education group and the comparison group during the course of the present study. The subjects in the present study indicated on the FABQ that they were afraid that activity would make their back pain worse. However, after reading the educational booklet and discussing the information with the physical therapist, most of the subjects in the education group agreed that normal daily activity was not harmful to their backs. For example, following 1 or 2 sessions of discussing the benefits of activity, many of the subjects in the education group came to their physical therapy sessions describing activities that they had previously been unable to perform. In contrast, most of the subjects in the comparison group continued to come to their physical therapy sessions reporting the amount of back pain that they were experiencing and describing particular activities that were aggravating their backs. In addition, most of the subjects in the comparison group voiced a fear that the therapeutic exercises might make their back pain worse. This fear of activity and exercise was not directly addressed by the education intervention that the subjects in the comparison group received.
In contrast, the subjects in the education group had already received some education intervention before they began the therapeutic exercises, and they did not voice nearly as much fear of the exercises as did the subjects in the comparison group. Given that no FABQ scores were obtained prior to discharge from physical therapy and return to work, the perception of the treating physical therapist that fear of pain was observed to be lower in the education group than in the comparison group could not be confirmed quantitatively, other than as the reported difference in the number of days required to return to work.
Most of the subjects in the education group stated that they did not use the relaxation techniques described in the educational booklet to cope with their LBP. They stated that once they understood that LBP during physical activity did not necessarily mean that they were harming their backs, they just made a conscious decision not to worry about or dwell on the pain. Having done so, they noticed less pain and consequently were able to become more active.
The results of the present study are consistent with a recent systematic review concluding that physical conditioning programs that incorporated cognitive-behavioral approaches were superior to physical conditioning programs that did not incorporate cognitive-behavioral approaches in reducing the number of work days lost because of neck and back pain.23 The results of the present study also are consistent with a randomized controlled trial demonstrating that people who benefited most from an exercise program with a cognitive-behavioral approach were those with high levels of fear-avoidance beliefs.13 Additionally, because the FABQ appears to be successful in identifying people at risk of not being able to return to work following a work-related low back injury,7,8 the results of the present study concur with the suggestion of others that FABQ results could help guide decisions regarding which people might benefit most from a cognitive-behavioral education approach and the type of education intervention to use.7,8,10,11
According to Fritz et al,24 people who have work-related LBP and who are treated with interventions that are based on impairments identified during a physical examination are more likely to return to regular work duties faster, have higher patient satisfaction scores, and have greater reductions in Oswestry Low Back Disability Questionnaire scores. That study also showed that the medical costs of this treatment approach are lower than those of treatments not based on an impairment classification system.24 Given the conclusions of Fritz et al,24 Klaber Moffitt et al,13 and the present study regarding education and counseling for people with fear-avoidance beliefs, adding a classification system and associated education and counseling for people with fear-avoidance beliefs may further improve the outcomes of physical therapy intervention for people with acute LBP.7,10,12 An earlier return to regular work duties may be facilitated when these strategies are concurrently implemented in patient care.
Study Limitations
A primary limitation of the present study was that data for secondary outcome variables, such as fear-avoidance beliefs, pain intensity, and disability questionnaire scores, were not collected. These data could have provided information on why one intervention resulted in a better return-to-work rate than another.
Other limitations of the present study included: (1) the small sample size, (2) narrowing of the sample cohort to only people without pathological diagnoses, (3) use of the sum of all 16 items of the FABQ to identify subjects with high levels of fear-avoidance beliefs rather than use of the commonly reported approaches based on the physical activity and work subscales of the FABQ,7,8,10,11,13,16 (4) the lack of information on people screened for eligibility in the study, and (5) alternate (as opposed to random) assignment. A study larger in scope (more people, multiple sites, and multiple practitioners) would increase the generalizability of the findings reported in the present study. Including only people without documented pathology of the spine also narrowed the generalizability of our findings. The large number of false-positive results obtained with paraclinical data (eg, imaging) in people with spinal pain might argue that the approach used in the present study might be beneficial. However, a separate study would need to be carried out in order to more definitively determine the effectiveness of education and counseling in people with such diagnoses. We did not have access to data on the people initially screened to enter the study. Such information would give the reader a better estimate of the prevalence of people who were eligible for the present study as well as a better idea of the proportion of people excluded and for what reasons (eg, herniated nucleus pulposus). Random assignment, instead of alternate assignment, of people into groups would constitute a stronger research design.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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| Footnotes |
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The protocol for this study was approved by the Institutional Review Board of Loma Linda University.
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