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Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions.

ABSTRACT: The purpose of this secondary analysis was 1) to examine patient expectations related to a variety of common interventions for low back pain (LBP) and 2) to determine the influence that specific expectations about spinal manipulation might have had on self-report of disability.We collected patients' expectations about the benefit of specific interventions for low back pain. We also collected patients' general expectations about treatment and tested the relationships among the expectation of benefit from an intervention, receiving that intervention and disability-related outcomes.Patients expected exercise and manual therapy interventions to provide more benefit than surgery and medication. There was a statistical association between expecting relief from thrust techniques and receiving thrust techniques, related to meeting the general expectation for treatment (chi-square: 15.5, P ?=? 0.008). This was not the case for patients who expected relief from thrust techniques but did not receive it (chi-square: 6.9, P ?=?0.4). Logistic regression modeling was used to predict change in disability at treatment visit 5. When controlling for whether the general expectations for treatment were met, intervention assignment and the interaction between intervention assignment and expectations regarding thrust techniques, the parsimonious model only included intervention as the significant contributor to the model (P < 0.001). The adjusted odds ratio of success comparing thrust techniques to non-thrust in this study was 41.2 (11.0, 201.7).The findings of this secondary analysis indicate that patients seeking intervention for LBP expect active interventions and manual therapy to significantly help improve their pain more than interventions like traction, rest, surgery, or medication. Additionally, in patients who meet the clinical prediction rule for good prognosis when managed with thrust techniques, treating with thrust techniques is more important than matching treatment to patient expectation.

SUBMITTER: Bishop MD

PROVIDER: S-EPMC3172953 | biostudies-literature | 2011 Feb

REPOSITORIES: biostudies-literature

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Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions.

Bishop Mark D MD Bialosky Joel E JE Cleland Josh A JA

The Journal of manual & manipulative therapy 20110201 1

<h4>Objectives</h4>The purpose of this secondary analysis was 1) to examine patient expectations related to a variety of common interventions for low back pain (LBP) and 2) to determine the influence that specific expectations about spinal manipulation might have had on self-report of disability.<h4>Methods</h4>We collected patients' expectations about the benefit of specific interventions for low back pain. We also collected patients' general expectations about treatment and tested the relation ...[more]

PMID: 22294850

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Project description:Retrospective cohort.The objectives of this study were (1) to examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients' general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes.Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions.We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked about their general expectations of benefit as well as their specific expectations for individual interventions. Next, we examined how these expectations related to the patients' ratings of the success of treatment at 1 and 6 months after treatment.Patients had positive expectations for treatment by a physical therapist, with more than 80% of patients expecting moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range-of-motion (54%) exercises. Very few patients thought surgery would improve their neck pain (less than 1%). At 1 month, patients who were unsure of experiencing complete pain relief had lower odds of reporting a successful outcome than patients expecting complete relief (odds ratio [OR] = 0.33; 95% confidence interval [CI]: 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% CI: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success (OR = 0.19; 95% CI: 0.05, 0.7), whereas definitely expecting to do more exercise increased the odds of success (OR = 11.4; 95% CI: 1.7, 74.7). Regarding self-reported disability assessed with the Neck Disability Index, patients who believed manipulation would help and received manipulation reported less disability than those who did not believe manipulation would help and both received manipulation (mean difference, -3.8; 95% CI: -5.9, -1.5; P = .006) and did not receive manipulation (mean difference, -5.7; 95% CI: -9.3, -2.1; P = .014). There was also an interaction between time and the expectation for complete relief.General expectations of benefit have a strong influence on clinical outcomes for patients with neck pain.Prognosis, level 2b-.

Project description:BackgroundA central element in the current debate about best practice management of non-specific low back pain (NSLBP) is the efficacy of targeted versus generic (non-targeted) treatment. Many clinicians and researchers believe that tailoring treatment to NSLBP subgroups positively impacts on patient outcomes. Despite this, there are no systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise. This systematic review was undertaken in order to determine the efficacy of such targeted treatment in adults with NSLBP.MethodMEDLINE, EMBASE, Current Contents, AMED and the Cochrane Central Register of Controlled Trials were electronically searched, reference lists were examined and citation tracking performed. Inclusion criteria were randomized controlled trials of targeted manual therapy and/or exercise for NSLPB that used trial designs capable of providing robust information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials needed to be hypothesis-testing studies published in English, Danish or Norwegian. Method quality was assessed using the criteria recommended by the Cochrane Back Review Group.ResultsFour high-quality randomized controlled trials of targeted manual therapy and/or exercise for NSLBP met the inclusion criteria. One study showed statistically significant effects for short-term outcomes using McKenzie directional preference-based exercise. Research into subgroups requires much larger sample sizes than traditional two-group trials and other included studies showed effects that might be clinically important in size but were not statistically significant with their samples sizes.ConclusionsThe clinical implications of these results are that they provide very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes. The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings. The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities.

Project description:ImportanceIn observational studies, patients' treatment outcome expectations have been associated with better outcomes (ie, a placebo response), whereas concerns about adverse side effects have been associated with an in increase in the negative effects of treatments (ie, a nocebo response). Some randomized trials have suggested that communication from clinicians could affect the treatment outcomes by changing patients' expectations.ObjectiveTo investigate whether treatment outcome expectations and reported adverse side effects could be affected by different briefing contents before a minimal acupuncture treatment in patients with chronic low back pain (CLBP).Design, setting, and participantsThis randomized single-blinded clinical trial was conducted among patients with CLBP at 1 outpatient clinic in Switzerland who had a pain intensity of at least 4 on a numeric rating scale from 0 to 10. Different recruitment channels were used to enroll patients. Data were collected from May 2016 to December 2017 and were analyzed from June to November 2018.InterventionsPatients were randomized to receive either a regular expectation briefing or a high expectation briefing (effectiveness) and either a regular adverse side effect briefing or an intense adverse side effect briefing (adverse side effect) in a 2 × 2 factorial design. The intervention (briefing sessions and written materials) was standardized and delivered before the acupuncture treatment, with additional booster informative emails provided during the 4-week, 8-session acupuncture course.Main outcomes and measuresThe primary end point was the patients' expectations regarding the effectiveness of the acupuncture treatment (Expectation for Treatment Scale [ETS]) after the briefing and the subsequent pain intensity (numeric rating scale). The primary end point for the adverse side effect briefing was the adverse side effect score at the end of the acupuncture treatment, derived from session-by-session assessments of adverse side effects.ResultsA total of 152 patients with CLBP (mean [SD] age, 39.54 [12.52] years; 100 [65.8%] women) were included. The estimated group difference (regular vs high) for the ETS was -0.16 (95% CI -0.81 to 0.50, P = .64), indicating no evidence for a difference between intervention groups. There was also no evidence for a difference in pain intensity at the end of the acupuncture treatment between the groups with different expectation briefings. The adverse side effects score in the group with the intense adverse side effect briefing were estimated to be 1.31 times higher (95% CI, 0.94 to 1.82; P = .11) than after a regular adverse side effect briefing, but the finding was not statistically significant.Conclusions and relevanceIn this study, suggestions regarding treatment benefits (placebo) and adverse side effects (nocebo) did not affect treatment expectations or adverse side effects. Information regarding adverse side effects might require more research to understand nocebo responses.Trial registrationGerman Clinical Trials Register Identifier: DRKS00010191.

Project description:Common mental disorders (CMDs) are among the leading causes of sick leave, and more knowledge on factors related to work participation and return-to-work (RTW) in CMDs is needed. The aim of this study was to investigate RTW-expectations and illness perceptions as predictors of benefit recipiency in CMDs.Study participants were enrolled in a randomised controlled trial and reported CMDs as a main obstacle for work participation. Three prespecified subgroups were included: people at risk of going on sick leave, people on sick leave (>3 weeks) or people on long-term benefits. Baseline questionnaire data and registry data at baseline and 6 months were used to investigate predictors of benefit recipiency at 6-month follow-up. Benefit recipiency included sickness benefits, disability pension, work assessment allowance and unemployment benefits.In this study, uncertain and negative RTW-expectations were strong predictors of benefit recipiency at 6 months follow-up. Illness perceptions predicted benefit recipiency in the unadjusted model, but not in the fully adjusted model. In the subgroup on sick leave, uncertain and negative RTW-expectations predicted benefit recipiency, while in the subgroup of people at risk of going on sick leave, negative RTW-expectations predicted benefit recipiency. In the subgroup on long-term benefits, only female gender predicted benefit recipiency.For people with CMDs, uncertain and negative RTW-expectations predict later benefit recipiency, and expectations seem particularly important for those at risk of or on sick leave. For those at risk of sick leave, benefit recipiency at follow-up denoted a transition onto sick leave or long-term benefit, while those on sick leave had remained so or were receiving long-term benefits. Addressing RTW-expectations in occupational healthcare services or vocational rehabilitation might be beneficial in early stages or even prior to a sick leave episode.http://www.clinicaltrials.gov, NCT01146730.

Project description:BackgroundLow back pain is a common reason for patients to seek medical care. Physician non-adherence to clinical guidelines has been observed. We investigated the extent to which patient expectations correspond to recommendations of the German national guideline for management of low back pain (G-LBP) and whether patient characteristics, history of LBP and previous treatment experience are associated with expectations.MethodsA cross-sectional study including patients from 13 general practices was conducted. Data were collected using a questionnaire. Inverse probability weights were used to address non-response bias. Descriptive analysis and multivariate logistic regression models were performed.ResultsA total of 977 patients were included in analyses (median age 57 years, 39% male). 75% of patients reported experiencing LBP currently or within the last year. More than 65% indicated they would agree to forgo further examinations if their LBP was judged by their physician to be of no serious concern. This was associated with the highest level of education and no prior imaging, and negatively associated with good-to-poor health status and moderate-to-severe pain intensity. 40% of participants expected imaging. The highest educational level, female gender and no prior imaging were associated with a decreased expectation of imaging. 70% expected prescriptions for massages. Females, participants with good-to-poor health status, current LBP or LBP in the last 12 months had an increased expectation for massages. Expectations for injection therapy (45%) were mainly associated with previous injections. Expectations for physiotherapy (64%) were associated with female gender, lower educational level, good-to-poor health status, current LBP or in the last 12 months. The perspective that daily activities should be continued (66%) was associated with female gender and higher educational level. Participants who agreed to the statement 'There is no effective treatment for LBP' (11%) had a poor health status, current LBP and a severe pain intensity.ConclusionPatient views regarding LBP management are partially concordant with guideline recommendations and are strongly influenced by previous treatment experiences and education level. Exploration of patient expectations and experiences in LBP treatment may help minimize dissatisfaction of patients expecting treatments not endorsed by guidelines and simultaneously increase physician guideline adherence.

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Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions.

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Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions.

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