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Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables
Scandinavian Journal of Pain 14 (2017) 67–68
Contents lists available at ScienceDirect
Scandinavian Journal of Pain journal homepage: www.ScandinavianJournalPain.com
Editorial comment
Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables Cecilie Røe a,b,∗ a b
University of Oslo, Faculty of Medicine, Oslo, Norway Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Oslo, Norway
In this issue of the Scandinavian Journal of Pain Ruud Groeneweg and co-workers [1] focus on the influence of treatment outcome expectancies on the treatment effect in patients with neck pain. They also included clinical and psychosocial variables previously documented to be associated with treatment outcome. In a prospective study including 181 patients followed at 7 and 26 weeks after receiving manual therapy or physiotherapy, hierarchical logistic regression analysis documented that expectancies explained slightly less than 10% of the variance in pain and 16–17% of the variance in functioning. In contrast to several previous prospective studies in neck pain, fear avoidance beliefs did not influence outcome significantly in the present study [2–5]. 1. Neck pain, fear and expectancies Neck pain is common, and often associated with substantially reduced function [6,7]. The course of neck pain may be long lasting [8] and closely associated with psychosocial factors [9,10]. Emotional distress, anxiety and depression are classic psychological factors influencing the prognosis of neck pain [11,12]. However, also beliefs and expectancies are assumed to influence the prognosis of painful conditions [5,13]. Fear avoidance beliefs are documented in numerous studies to act as mediator and moderator of pain [3–5]. Yet, another dimension of psychology is expectations and credibility, i.e. thoughts and feelings about treatment and outcome. Although, to some extent explored in relation to placebo and nocebo effects, expectations are, as Ruud Groeneweg et al. [1] point out, seldom included together with the more classical psychosocial factors in the spinal pain literature. Hence, expectancies outweighing fear avoidance beliefs in the present study is an important finding and needs to be pursued in future studies as well. 2. Challenges in expectation research There are yet several challenges to be resolved within this area of research. One may assume that expectations are individual and
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.10.003. ∗ Corresponding author at: Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Pbox 4950, Nydalen, 0424 Oslo, Norway. E-mail address: [email protected]
heterogeneous. Hence, expectations are likely to be related to a particular population. Socioeconomic background [14], previous health experiences [15], personality and emotional distress [16] may affect expectations. Furthermore, the expectations may be related to the particular complaint or diagnosis, to the subsequent treatment [17] or to the prognosis and outcome [18]. In the present study by Groeneweg et al. [1], the patients consented to participate in a randomized treatment trial which may be an explanation for their high level of expectations. In contrast, Skatteboe et al. [19] found that among a mixed population referred to a specialized outpatient clinic, only one third of the patients expected changes in their condition. In addition, even though the pain level was rather high and two thirds of the patients had multiple pain sites, their disability as evaluated by Neck Disability Index was relatively low in the present study compared to other studies [20,21]. In addition, the way we measure credibility and expectation may influence the results. Using a properly translated and validated instrument like the Credibility Expectancy Questionnaire (CEQ) is a strength in the present study. However the questions in CEQ are closely related to the treatment. Several other measurements exist [22], which may capture different dimensions of expectancies and influence the diverging results. However, the systematic review by Mondloch et al. [13], supports the results by Groeneweg et al. [1], and documents that positive treatment expectations were associated with improved health outcomes in 15 of 16 studies.
3. Clinical utility of expectations The article by Groeneweg et al. [1], supports the need of better assessment of patients expectations in the clinical setting. However, it is worth to note that unrealistic expectations, whether high or low, are suggested to negatively influence outcomes [23]. Hence, moving to clinical utilizations of expectations, we may need to adjust the expectations to the documented effect of the treatment and prognosis. Health care professionals seem to have the possibility to do so [24] and such adjustments have in itself been shown to improve outcome [25]. In conclusion, the assessment and discussion of expectations in the clinical consultations is a cheap and viable direction to improve communication and care of patients with painful musculoskeletal conditions.
http://dx.doi.org/10.1016/j.sjpain.2016.10.006 1877-8860/© 2016 Published by Elsevier B.V. on behalf of Scandinavian Association for the Study of Pain.
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C. Røe / Scandinavian Journal of Pain 14 (2017) 67–68
Conflict of interest None declared. References [1] Groeneweg R, Haanstra T, Bolman CAW, Oostendorp RAB, van Tulder MW, Ostelo RWJG. Treatment success in neck pain: the added predictive value of psychosocial variables in addition to clinical variables. Scand J Pain 2017 [in this issue]. [2] Marchand GH, Myhre K, Leivseth G, Sandvik L, Lau B, Bautz-Holter E, Roe C. Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial. BMC Musculoskelet Disord 2015;16:94. [3] Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizinga prognostic factor for outcome in patients with low back pain: a systematic review. Spine J 2014;14:2639–57. [4] Wertli MM, Rasmussen-Barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J 2014;14:2658–78. [5] Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J 2014;14: 816–36. [6] Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25:1973–6. [7] Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995;20:473–7. [8] Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a systematic review. Pain 1998;77:1–13. [9] Cote P, van d V, Cassidy JD, Carroll LJ, Hogg-Johnson S, Holm LW, Carragee EJ, Haldeman S, Nordin M, Hurwitz EL, Guzman J, Peloso PM. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33:S60–74. [10] Hill J, Lewis M, Papageorgiou AC, Dziedzic K, Croft P. Predicting persistent neck pain: a 1-year follow-up of a population cohort. Spine 2004;29:1648–54. [11] Holmberg SA, Thelin AG. Primary care consultation, hospital admission, sick leave and disability pension owing to neck and low back pain: a 12-year prospective cohort study in a rural population. BMC Musculoskelet Disord 2006;7:66.
[12] Wirth B, Humphreys BK, Peterson C. Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal observational study. Chiropr Man Therap 2016;24:9. [13] Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes. Can Med Assoc J 2001;165:174–9. [14] Ozegovic D, Carroll LJ, David CJ. Does expecting mean achieving? The association between expecting to return to work and recovery in whiplash associated disorders: a population-based prospective cohort study. Eur Spine J 2009;18:893–9. [15] Janzen JA, Silvius J, Jacobs S, Slaughter S, Dalziel W, Drummond N. What is a health expectation? Developing a pragmatic conceptual model from psychological theory. Health Expect 2006;9:37–48. [16] Kapoor S, Shaw WS, Pransky G, Patterson W. Initial patient and clinician expectations of return to work after acute onset of work-related low back pain. J Occup Environ Med 2006;48:1173–80. [17] Lurie JD, Berven SH, Gibson-Chambers J, Tosteson T, Tosteson A, Hu SS, Weinstein JN. Patient preferences and expectations for care: determinants in patients with lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 2008;33:2663–8. [18] Haanstra TM, Hanson L, Evans R, van Nes FA, de Vet HC, Cuijpers P, Ostelo RW. How do low back pain patients conceptualize their expectations regarding treatment? Content analysis of interviews. Eur Spine J 2013;22:1986–95. [19] Skatteboe S, Roe C, Fagerland MW, Granan LP. Expectations for treatment outcomes in neck/back patients regarding improvements in pain and function: a cross-sectional pilot study. Eur J Phys Rehabil Med 2014;50. [20] Anstey R, Kongsted A, Kamper S, Hancock MJ. Are people with whiplashassociated neck pain different from people with nonspecific neck pain? J Orthop Sports Phys Ther 2016;46:894–901. [21] Jorritsma W, Dijkstra PU, de Vries GE, Geertzen JH, Reneman MF. Detecting relevant changes and responsiveness of neck pain and disability scale and neck disability index. Eur Spine J 2012;21:2550–7. [22] van HF, Ostelo RW, Cuijpers P, de VR, Riphagen II, de Vet HC. Treatmentrelated and patient-related expectations of patients with musculoskeletal disorders: a systematic review of published measurement tools. Clin J Pain 2010;26:470–88. [23] Iles RA, Davidson M, Taylor NF, O’Halloran P. Systematic review of the ability of recovery expectations to predict outcomes in non-chronic non-specific low back pain. J Occup Rehabil 2009;19:25–40. [24] Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013;11:527–34. [25] Di BZ, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757–62.
Contents lists available at ScienceDirect
Scandinavian Journal of Pain journal homepage: www.ScandinavianJournalPain.com
Editorial comment
Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables Cecilie Røe a,b,∗ a b
University of Oslo, Faculty of Medicine, Oslo, Norway Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Oslo, Norway
In this issue of the Scandinavian Journal of Pain Ruud Groeneweg and co-workers [1] focus on the influence of treatment outcome expectancies on the treatment effect in patients with neck pain. They also included clinical and psychosocial variables previously documented to be associated with treatment outcome. In a prospective study including 181 patients followed at 7 and 26 weeks after receiving manual therapy or physiotherapy, hierarchical logistic regression analysis documented that expectancies explained slightly less than 10% of the variance in pain and 16–17% of the variance in functioning. In contrast to several previous prospective studies in neck pain, fear avoidance beliefs did not influence outcome significantly in the present study [2–5]. 1. Neck pain, fear and expectancies Neck pain is common, and often associated with substantially reduced function [6,7]. The course of neck pain may be long lasting [8] and closely associated with psychosocial factors [9,10]. Emotional distress, anxiety and depression are classic psychological factors influencing the prognosis of neck pain [11,12]. However, also beliefs and expectancies are assumed to influence the prognosis of painful conditions [5,13]. Fear avoidance beliefs are documented in numerous studies to act as mediator and moderator of pain [3–5]. Yet, another dimension of psychology is expectations and credibility, i.e. thoughts and feelings about treatment and outcome. Although, to some extent explored in relation to placebo and nocebo effects, expectations are, as Ruud Groeneweg et al. [1] point out, seldom included together with the more classical psychosocial factors in the spinal pain literature. Hence, expectancies outweighing fear avoidance beliefs in the present study is an important finding and needs to be pursued in future studies as well. 2. Challenges in expectation research There are yet several challenges to be resolved within this area of research. One may assume that expectations are individual and
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.10.003. ∗ Corresponding author at: Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Pbox 4950, Nydalen, 0424 Oslo, Norway. E-mail address: [email protected]
heterogeneous. Hence, expectations are likely to be related to a particular population. Socioeconomic background [14], previous health experiences [15], personality and emotional distress [16] may affect expectations. Furthermore, the expectations may be related to the particular complaint or diagnosis, to the subsequent treatment [17] or to the prognosis and outcome [18]. In the present study by Groeneweg et al. [1], the patients consented to participate in a randomized treatment trial which may be an explanation for their high level of expectations. In contrast, Skatteboe et al. [19] found that among a mixed population referred to a specialized outpatient clinic, only one third of the patients expected changes in their condition. In addition, even though the pain level was rather high and two thirds of the patients had multiple pain sites, their disability as evaluated by Neck Disability Index was relatively low in the present study compared to other studies [20,21]. In addition, the way we measure credibility and expectation may influence the results. Using a properly translated and validated instrument like the Credibility Expectancy Questionnaire (CEQ) is a strength in the present study. However the questions in CEQ are closely related to the treatment. Several other measurements exist [22], which may capture different dimensions of expectancies and influence the diverging results. However, the systematic review by Mondloch et al. [13], supports the results by Groeneweg et al. [1], and documents that positive treatment expectations were associated with improved health outcomes in 15 of 16 studies.
3. Clinical utility of expectations The article by Groeneweg et al. [1], supports the need of better assessment of patients expectations in the clinical setting. However, it is worth to note that unrealistic expectations, whether high or low, are suggested to negatively influence outcomes [23]. Hence, moving to clinical utilizations of expectations, we may need to adjust the expectations to the documented effect of the treatment and prognosis. Health care professionals seem to have the possibility to do so [24] and such adjustments have in itself been shown to improve outcome [25]. In conclusion, the assessment and discussion of expectations in the clinical consultations is a cheap and viable direction to improve communication and care of patients with painful musculoskeletal conditions.
http://dx.doi.org/10.1016/j.sjpain.2016.10.006 1877-8860/© 2016 Published by Elsevier B.V. on behalf of Scandinavian Association for the Study of Pain.
68
C. Røe / Scandinavian Journal of Pain 14 (2017) 67–68
Conflict of interest None declared. References [1] Groeneweg R, Haanstra T, Bolman CAW, Oostendorp RAB, van Tulder MW, Ostelo RWJG. Treatment success in neck pain: the added predictive value of psychosocial variables in addition to clinical variables. Scand J Pain 2017 [in this issue]. [2] Marchand GH, Myhre K, Leivseth G, Sandvik L, Lau B, Bautz-Holter E, Roe C. Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial. BMC Musculoskelet Disord 2015;16:94. [3] Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizinga prognostic factor for outcome in patients with low back pain: a systematic review. Spine J 2014;14:2639–57. [4] Wertli MM, Rasmussen-Barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J 2014;14:2658–78. [5] Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J 2014;14: 816–36. [6] Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25:1973–6. [7] Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995;20:473–7. [8] Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a systematic review. Pain 1998;77:1–13. [9] Cote P, van d V, Cassidy JD, Carroll LJ, Hogg-Johnson S, Holm LW, Carragee EJ, Haldeman S, Nordin M, Hurwitz EL, Guzman J, Peloso PM. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33:S60–74. [10] Hill J, Lewis M, Papageorgiou AC, Dziedzic K, Croft P. Predicting persistent neck pain: a 1-year follow-up of a population cohort. Spine 2004;29:1648–54. [11] Holmberg SA, Thelin AG. Primary care consultation, hospital admission, sick leave and disability pension owing to neck and low back pain: a 12-year prospective cohort study in a rural population. BMC Musculoskelet Disord 2006;7:66.
[12] Wirth B, Humphreys BK, Peterson C. Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal observational study. Chiropr Man Therap 2016;24:9. [13] Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes. Can Med Assoc J 2001;165:174–9. [14] Ozegovic D, Carroll LJ, David CJ. Does expecting mean achieving? The association between expecting to return to work and recovery in whiplash associated disorders: a population-based prospective cohort study. Eur Spine J 2009;18:893–9. [15] Janzen JA, Silvius J, Jacobs S, Slaughter S, Dalziel W, Drummond N. What is a health expectation? Developing a pragmatic conceptual model from psychological theory. Health Expect 2006;9:37–48. [16] Kapoor S, Shaw WS, Pransky G, Patterson W. Initial patient and clinician expectations of return to work after acute onset of work-related low back pain. J Occup Environ Med 2006;48:1173–80. [17] Lurie JD, Berven SH, Gibson-Chambers J, Tosteson T, Tosteson A, Hu SS, Weinstein JN. Patient preferences and expectations for care: determinants in patients with lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 2008;33:2663–8. [18] Haanstra TM, Hanson L, Evans R, van Nes FA, de Vet HC, Cuijpers P, Ostelo RW. How do low back pain patients conceptualize their expectations regarding treatment? Content analysis of interviews. Eur Spine J 2013;22:1986–95. [19] Skatteboe S, Roe C, Fagerland MW, Granan LP. Expectations for treatment outcomes in neck/back patients regarding improvements in pain and function: a cross-sectional pilot study. Eur J Phys Rehabil Med 2014;50. [20] Anstey R, Kongsted A, Kamper S, Hancock MJ. Are people with whiplashassociated neck pain different from people with nonspecific neck pain? J Orthop Sports Phys Ther 2016;46:894–901. [21] Jorritsma W, Dijkstra PU, de Vries GE, Geertzen JH, Reneman MF. Detecting relevant changes and responsiveness of neck pain and disability scale and neck disability index. Eur Spine J 2012;21:2550–7. [22] van HF, Ostelo RW, Cuijpers P, de VR, Riphagen II, de Vet HC. Treatmentrelated and patient-related expectations of patients with musculoskeletal disorders: a systematic review of published measurement tools. Clin J Pain 2010;26:470–88. [23] Iles RA, Davidson M, Taylor NF, O’Halloran P. Systematic review of the ability of recovery expectations to predict outcomes in non-chronic non-specific low back pain. J Occup Rehabil 2009;19:25–40. [24] Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013;11:527–34. [25] Di BZ, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757–62.