does a physiotherapy cognitive-behavioural chronic low back pain programme alter patients

430 Pages·2016·5.52 MB·English

by  Sharon Braddock

DOES A PHYSIOTHERAPY
COGNITIVE-BEHAVIOURAL CHRONIC
LOW BACK PAIN PROGRAMME
ALTER PATIENTS’ HEALTH LOCUS
OF CONTROL?
A Thesis Submitted In Partial Fulfilment of the
Requirements of Manchester Metropolitan
University for the Degree of Professional Doctorate

Sharon Braddock
September 2016

Faculty of Health Psychology and Social Care
Manchester Metropolitan University
CONTENTS Page

Table of contents i
List of tables viii
List of figures xi
Appendices xiii
Abbreviations xiv
Declaration and Acknowledgement xv
Abstract xvi

Table of contents
CHAPTER 1 INTRODUCTION TO THE STUDY 1
1.1 Introduction 1
1.2 The complexity of NSCLBP 1
1.2.1 Category of pain 1
1.2.2 Pain is a product of the brain 2
1.2.3 Definition of pain 3
1.2.4 Different theoretical models in explaining NSCLBP 4
1.3 Theory of the cognitive-behavioural principles 8
1.4 Conceptual framework underpinned by clinical experiences 9
1.5 A brief introduction of HLOC 11
1.5.1 Definition and a brief overview of HLOC in health researches 11
1.5.2 Relevancy of HLOC for physiotherapy management of NSCLBP 12
1.6 A gap in literature 14
1.7 Research question and specific aims of the study 15
1.8 Conclusion 15

CHAPTER 2 LITERATURE REVIEW 16
2.1 Introduction 16
PART I
2.2 LBP- The clinical problem 18
i
2.3 Clinical guidelines of the management of NSCLBP 18
2.3.1 The 100 hours guideline recommendation 20
2.4 Role of physiotherapist 21
2.5 Exercise therapy in NSCLBP management 22
2.5.1 Evidence on exercise therapy in NSCLBP 23
2.5.2 Summary of evidence on the effectiveness of exercise therapy 25
2.5.3 Role of psychological factors on the effect of exercise therapy 25
2.6 The CBA treatment in physiotherapy management of NSCLBP 26
2.6.1 Evidence on the clinical effectiveness of CBA active 27
rehabilitation led by physiotherapists
2.6.2 Summary of evidence on the clinical effectiveness of CBA 31
active rehabilitation led by physiotherapists
2.7 Evidence of the effectiveness of CBA rehabilitation when 32
targeting patients with psychosocial characteristics
2.7.1 Summary of evidence on the effectiveness of CBA 34
rehabilitation when targeting patients with psychosocial
characteristics
2.8 Effectiveness of CBA intervention in altering HLOC 35
2.8.1 Evidence reviewing the effect of CBA intervention in altering 36
HLOC using MHLC
2.8.2 Evidence reviewing the effect of CBA intervention in altering 39
HLOC using composite scores or outcome measures that is re-
constructed on the basis of MHLC
2.8.3 Summary of evidence on the effect of CBA intervention in 41
altering HLOC
2.9 Importance of self-management of NSCLBP 43
2.9.1 Evidence of the effectiveness of CBA active rehabilitation on 45
patients’ self-management
2.9.2 Summary of evidence on the effectiveness of CBA active 48
rehabilitation on patients’ self-management
2.10 Cost 48
2.10.1 Evidence on cost evaluation of the physiotherapy-led CBCLBP 49
programme
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PART II
2.11 The fear-avoidance model and its constitutive components 53
2.11.1 Pain intensity 54
2.11.2 Pain-related fear 61
2.11.3 Disability 66
2.11.4 Summary of evidence on the relationship between pain 67
intensity, disability and FAB
2.11.5 Re-think the fear-avoidance model 68
2.12 HLOC- The relationship between HLOC and health-related 68
behaviour in patient and healthy population
2.13 Evidence on HLOC in NSCLBP outcomes 70
2.13.1 Relationship between HLOC and the clinical outcomes of 70
NSCLBP
2.13.2 Relationship between HLOC and cognitive-behavioural 72
variables of NSCLBP
2.13.3 Summary of key findings of HLOC in NSCLBP 75
2.13.4 Methodological consideration of the evidence on HLOC in 75
NSCLBP
2.14 Summary: Current state of knowledge relevant to present 76
study
2.14.1 Limitations of our knowledge 77
2.15 Conclusion 77

CHAPTER 3 METHODOLOGY 78
3.1 Introduction 78
3.2 Overall design 78
3.3 Methodological consideration 80
3.3.1 Selection of research method 80
3.3.2 Same- subject design 81
3.3.3 Comparing different types of same-subject designs 81
3.3.4 Implications of the clinician-researcher dual role 83
3.4 Ethical consideration 83
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3.5 Selection of participants 85
3.5.1 Sample selection 85
3.5.2 Setting 86
3.5.3 Inclusion and exclusion criteria 86
3.5.4 Sample size calculation 88
3.6 Study protocol 88
3.6.1 Recruitment process 88
3.6.2 Intervention 93
3.6.3 Aims of the intervention 93
3.6.4 Delivery of the intervention 94
3.6.5 Education 95
3.6.6 Exercise 98
3.6.7 Homework 99
3.7 Outcome measures 99
3.7.1 Outcome measure 1: HLOC 101
3.7.2 Outcome measure 2: Pain intensity 105
3.7.3 Outcome measure 3: Disability 106
3.7.4 Outcome measure 4: FAB 107
3.7.5 Outcome measure 5: Attitudes Toward Back Pain Self- Care 108
3.8 Data collection and data management 109
3.9 Data analysis 111
3.10 Economic evaluation 114
3.10.1 Provider costs 116
3.10.2 Patient costs 121
3.10.3 Societal costs 122
3.11 Minimising bias and confounding variables 123
3.12 Conclusion 123

CHAPTER 4 RESULTS 124
4.1 Introduction 124
4.2 Overview of recruitment and data collection 124
4.3 Demographics and background information of included 125
patients
iv
4.3.1 Comparison of demographics and background information 127
between patients who completed the programme and those
who dropped out of the programme
4.3.2 Comparison of baseline outcome measures between patients 128
who completed the programme and those who dropped out
of the programme
4.4 Baseline characteristics of included patients who completed 131
the study
4.5 Aim 1- To assess the effect of the CBCLBP programme on 132
patients’ HLOC
4.5.1 The effect of the CBCLBP programme on ILOC 132
4.5.2 The effect of the CBCLBP programme on ELOC 135
4.5.3 The effect of the CBCLBP programme on CLOC 138
4.5.4 Summary of the effect of the CBCLBP programme on patients’ 141
HLOC
4.6 Aim 2- To examine the effect of the CBCLBP programme on 142
pain intensity, disability and fear avoidance belief
4.6.1 The effect of CBCLBP programme on pain intensity 142
4.6.2 The effect of CBCLBP programme on disability 144
4.6.3 The effect of CBCLBP programme on FAB 147
4.7 Aim 3- To determine if there is any relationship between 150
patients’ HLOC, pain intensity, disability and FAB
4.7.1 Correlation 150
4.7.1.1 Correlation between pain intensity, disability and FAB 150
4.7.1.2 Correlation between HLOC and pain intensity 150
4.7.1.3 Correlation between HLOC and disability 150
4.7.1.4 Correlation between HLOC and FAB 151
4.7.2 Hierarchical multiple regression 153
4.7.2.1 When pain intensity as the outcome 153
4.7.2.2 When disability as the outcome 155
4.7.2.3 When FAB as the outcome 157

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4.8 Aim 4- To examine patients’ self-care attitude toward their 160
back pain in terms of their desire in future use of healthcare
and prescription pain medication as a result of the
programme
4.9 Aim 5- To examine the cost of back care per change of ILOC, 163
and the cost of the CBCLBP programme from a provider’s,
patient and societal perspective
4.9.1 The cost of a six-week CBCLBP programme from a provider’s, 165
patient and societal perspective
4.9.1.1 Provider’s cost incurred in a six week CBCLBP programme 165
4.9.1.2 Patient cost incurred in a six week CBCLBP programme 168
4.9.1.3 Societal cost incurred in a six week CBCLBP programme 171
4.9.2 The cost per change of ILOC as a result of the CBCLBP 172
programme
4.9.3 To determine the longer-term (6-months) cost of back care 173
for patient and provider
4.9.4 Key findings of economic evaluation 177
4.10 Conclusion 177

CHAPTER 5 DISCUSSION 178
5.1 Introduction 178
5.2 Comparison between patients who completed the CBCLBP 179
programme and those who dropped out of the programme
5.3 Aim 1- The effect of the CBCLBP programme on HLOC 182
5.4 Aim 2- To examine the effect of the CBCLBP programme on 191
pain intensity, disability and FAB
5.5 Aim 3- To determine if there is any relationship between 208
patients’ HLOC, pain intensity, disability and FAB
5.5.1 Correlation between HLOC, pain intensity, disability and FAB 208
5.5.2 To determine what extent changes in ILOC, ELOC, CLOC and 216
other variables can predict changes in pain intensity, disability
and FAB
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5.5.2.1 When pain intensity is the outcome 216
5.5.2.2 When disability is the outcome 218
5.5.2.3 When FAB is the outcome 221
5.6 Aim 4- To determine patients’ self-care attitude toward their 226
back pain in terms of their desire in future use of healthcare
and prescription pain medication as a result of the CBCLBP
programme
5.7 Aim 5- The cost per change of ILOC as a result of the CBCLBP 235
programme
5.7.1 The cost of a six-week CBCLBP programme from a provider’s, 235
patient and societal perspective
5.7.2 The cost per change of ILOC as a result of the CBCLBP 240
programme
5.7.3 The longer-term (6-months) cost of back care from a patient 242
and provider’s perspective

CHAPTER 6 SUMMARY, RECOMMENDATIONS AND CONCLUSIONS 247
6.1 Introduction 247
6.2 Summary- Aims and key findings of the study 248
6.3 Strength and weakness of the study 250
6.3.1 The innovations and benefits of the study 250
6.3.2 Strength of the study 252
6.3.3 Weakness of the study 257
6.4 Key learning from the research 263
6.5 Implications and recommendations 266
6.5.1 Implication for practice 266
6.5.2 Implication for research 271
6.6 Conclusion 272
6.7 Key messages 275

APPENDICES 276
REFERENCES 374

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List of Tables
Table 4.1 To show demographics and background information of 126
patients completed the intervention compared with patients
who dropped out
Table 4.2 To summarize the Pearson Chi-Square and Fisher’s exact tests 127
to a series of categorical variables between those patients
who completed the programme and those who dropped out
the programme
Table 4.3 Baseline characteristics of patients who completed the 129
intervention compared with patients who dropped out
Table 4.4 Mann-Whitney U-Test to examine the differences in 130
continuous variable between those patients who completed
the programme and those who dropped out
Table 4.5 Pre- and post-treatment mean values and standard deviation 132
of ILOC
Table 4.6 To examine the significant difference of patients’ mean ILOC 134
score between each phase using Wilcoxon signed-rank test
Table 4.7 Pre- and post-treatment mean values and standard deviation 135
of ELOC
Table 4.8 To examine the significant difference of patients’ mean ELOC 136
score between each phase using Wilcoxon signed-rank test
Table 4.9 Pre- and post-treatment mean values and standard deviation 138
of CLOC
Table 4.10 To examine the significant difference of patients’ mean CLOC 140
score between each phase using Wilcoxon signed-rank test
Table 4.11 Pre- and post-treatment mean values and standard deviation 142
of pain intensity as evaluated by VAS
Table 4.12 To examine the significant difference of patients’ mean pain 143
intensity score between each phase
Table 4.13 Pre- and post-treatment mean values and standard deviation 144
of disability as evaluated by RMQ

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Table 4.14 To examine the significant difference of patients’ mean 146
disability score between each phase using Wilcoxon signed-
rank test
Table 4.15 Pre- and post-treatment mean values and standard deviation 147
of FAB as evaluated by TSK
Table 4.16 To examine the significant difference of patients’ mean FAB 149
score between each phase using Wilcoxon signed-rank test
Table 4.17 Correlations between the change scores that occurred for 152
each of the self-reported measures
Table 4.18 Hierarchical regression analysis with change in pain intensity 154
as the outcome and change in cognitive factors as predictor
variables
Table 4.19 Hierarchical regression analysis with change in disability as the 156
outcome and change in cognitive factors as predictor
variables
Table 4.20 Hierarchical regression analysis with change in FAB as the 158
outcome and change in cognitive factors as predictor
variables
Table 4.21 Pre- and post- treatment mean values and standard deviation 160
of self-care attitude as evaluated by SCQ
Table 4.22 To examine the significant difference of patients’ attitude 162
toward self-care between each phase using Wilcoxon signed-
rank test
Table 4.23 Key unit costs used that consumed during the study 164
Table 4.24 Staffing time and staffing cost to provide the six-week CBCLBP 165
programme
Table 4.25 Price of gym equipments and hydrotherapy equipments 167
Table 4.26 Characteristics of patient costs (i.e. patients’ out-of pocket 169
expenses) incurred during the six-week CBCLBP programme
Table 4.27 Patient costs incurred during the six-week CBCLBP programme 170
Table 4.28 Societal costs during the six-week CBCLBP programme 171

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