Abstract
Background
Defining individual educational, or learning, targets is part of the initial educational assessment in rehabilitation programs, but no data are available on how to achieve these goals.
Objective
We aimed to evaluate whether educational objectives established with the patient as part of a functional spine restoration program integrating self-care sessions were met after the program and associated therapy outcomes.
Methods
This retrospective study involved 104 patients with chronic low-back pain who participated in a self-care rehabilitation program between 2008 and 2012. The program included both physical and educational approaches to dealing with the condition. The main evaluation criterion was achieving the educational objectives established with the patient at 6 months. Secondary criteria were a return to work, pain intensity and impact on function, satisfaction with the program and implementation of physical activity and self-rehabilitation at 6 months.
Results
At 6 months, 55% of the established educational objectives were fully achieved and satisfaction was close to 90%. Significantly, more patients were involved in a physical activity at 6 and 12 months and self-rehabilitation exercises at 6 months as compared with at inclusion. Overall, 43.4% were working at inclusion, 64.2% at 6 months and 58.2% at 12 months ( P < 0.05 compared with inclusion). Pain intensity and scores from the Quebec, Dallas and FABQ questionnaires had significantly decreased at 6 months.
Conclusion
For more than half of the patients in this self-care rehabilitation program, educational objectives established with the patient were achieved, with a positive effect on returning to work and both professional and physical activities at 6 and 12 months.
1
Introduction
Chronic low-back pain is the first cause of disability in people younger than 45 and the main reason for taking sick leave from work; its prevalence seems to be increasing . The disease is a chronic multi-factor pathology requiring multidisciplinary care management to mitigate physical deconditioning and to act on psychological and socio-professional factors . The effectiveness of dynamic care programs has been validated in France and in other countries for their impact on returning to work, psychological criteria and quality of life . To optimize therapeutic results and restore some autonomy in patients with chronic low-back pain, these programs are associated with an educational, or learning, component to position patients at the core of their care management process and help them acquire and maintain competencies to efficiently manage their chronic disease. Educational objectives could include learning to perform previously avoided activities and movements, focusing on preventive attitudes (self-rehabilitation, physical activity, returning to work, proper life habits, relaxation); working on emotional components and enhancing feelings of self-efficacy; acquiring self-care and self-management abilities for dealing with a chronic disease (pain management); and reinforcing the acceptance of the chronic pain.
However, the place of self-care in chronic low-back pain has not been clearly defined and its effectiveness has not been validated by evidence-based data . Although we cannot dissociate the specific effects of learning components within multidisciplinary programs on pain, function or returning to work, an initial educational assessment enables allows for setting individual objectives, which can become successful outcome criteria if they are met.
This retrospective study aimed to evaluate whether educational, or learning, objectives established with the patient were met in a functional spine restoration and self-care program at Montpellier University Hospital as well as therapy outcomes.
2
Methods
2.1
Patients
Patients were included in the study from 2008 to 2012 if they had chronic unspecific low-back pain according to the French health authority (Haute Autorité de santé) that progressed over 3 months; the pain affected professional activities, whether the patient was working, on sick leave or on workers’ compensation due to an occupational accident; conventional therapeutic treatments and outpatient rehabilitation had failed; and the patient was highly motivated for the program with an objective of returning to work and/or resuming sport activities. We excluded all patients with secondary low-back pain (infectious, inflammatory, traumatic, malignant), cardiovascular abnormalities screened during a stress test (performed after age of 50 or presence of cardiovascular risk factors) or psychiatric disorders (taking psychotic drugs) not compatible with program adherence.
Data were collected from charts of all patients who participated in the program. Patients who did not come to the consultation at months 6 and 12 were contacted by phone to collect the relevant data. Data were collected on age, sex, BMI, practice of physical activities before entering the program; clinical elements related to the low-back pain (duration of low-back pain, presence or not of associated disc pain, history of spine surgery, pain measured on a visual analog scale [VAS], analgesic consumption, history of physical therapy in the past 6 months); socio-professional situation; and physical features (Schober’s test, modified Schober’s test, fingertip-to-floor [FTF] distance, popliteal fossa [PF], heel-to-buttock distance [HTB], and flexor endurance tests according to Shirado and trunk extensor tests according to Sorensen).
2.2
Program objectives
Objectives set with the patient the day before the program began were evaluated at 6 months. Nurses from the physical medicine and rehabilitation unit, who were trained in health education needs, performed an individual educational assessment with the patient. This standardized assessment explored the individual context, history of the disease, knowledge, pain evaluation and its impact, patient expectations, consequences of the disease, and coping strategies and life goals of these patients. After this individual interview, therapy objectives were set. The objectives could focus on returning to work, resuming physical activities, or better pain management, and improved body knowledge. At 6 and 12 months, patients were seen again by the nurses to determine whether the objectives were met, not met but attainable, or impossible to meet.
For healthcare professionals, the educational objectives of the program were to progressively expose the patient to previously avoided activities and movements, associated with cognitive training on fears and beliefs; reinforcing adapted behaviors, focusing on preventive attitudes (self-rehabilitation, physical activity, returning to work, proper life habits, relaxation); working on emotional components and enhancing the patient’s feelings of self-efficacy; acquiring self-care and self-management competencies for dealing with a chronic disease (pain management); and reinforcing the acceptance of the chronic pain. Table 1 lists the workshops involved. Documents on low-back pain and a guide with self-help exercises were given to the patient at the end of the program.
| Name of the session and session moderator | Educational objective |
|---|---|
| Muscle tone rehabilitation Physical therapist: 4 h/week | Learning self-rehabilitation techniques |
| Strength-training Physical therapist 4 h/week | Implementing regular physical activity |
| Stretching Physical therapist 2 h 30/week | Learning self-rehabilitation techniques |
| Balneotherapy Physical therapist 2 h/week | Learning self-rehabilitation techniques |
| Yoga Physical therapist 5 h/week | Learning relaxation and self-rehabilitation techniques Establishing a relationship between psychological factors and their physical expression |
| Feldenkrais Occupational therapist 2 h 30/week | Knowing how to move differently without pain |
| Ergonomics Occupational therapist 5 h/week | Working on enhancing knowledge on low-back pain mechanisms, notions of anatomy and spine biomechanics Physical and posture reconditioning |
| Pain Nurse 1 h/week | Understanding the mechanisms of chronic pain Learning to cope with a painful episode Understanding the importance of good life habits |
| Support group Psychologist, physician 1 h 30/week | Establishing a relationship between psychological factors and chronic pain |
| Medical synthesis The entire team 1 h/week | Positive reinforcement |
At 6 and 12 months, program satisfaction was simply evaluated on a 5-point Likert scale (very satisfied, satisfied, moderately satisfied, not very satisfied, or disappointed). Function was assessed by the Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale , impact on pain by the Dallas pain questionnaire , and fear and avoidance beliefs by the Fear-Avoidance Beliefs Questionnaire (FABQ) .
2.3
Intervention
The proposed program was validated as a self-care program. It involved a multidisciplinary team with a physical medicine and rehabilitation physician, a rheumatologist, an occupational medicine physician, a social worker, physical therapists, occupational therapists, nurses, a psychologist, a dietician and a pain physician. For each program session, 4 to 10 patients participated for 5 days a week from Monday to Friday, 8 h/day, for 3 weeks, as outpatients or inpatients. The program included both physical and educational approaches. The care management was mainly group-based. Specific attention was paid to the homogeneity of the information delivered by all healthcare professionals (importance of movement, accepting chronic pain, patient autonomy).
2.4
Ethics statement
The study was approved by the institutional review board (No. 15/1004). Patients gave their oral consent after being informed about the study objectives and before inclusion and their written consent for use of data on inclusion. The study was conducted according to good clinical practices and the declaration of Helsinki.
2.5
Statistical analysis
Quantitative variables are described with mean ± SD or median (range). Qualitative variables are described by number (%). For quantitative analyses, we used Student t -test or Wilcoxon-Mann-Whitney test and for qualitative analyses, Chi 2 and Fisher’s exact test. P < 0.05 was considered statistically significant.
2
Methods
2.1
Patients
Patients were included in the study from 2008 to 2012 if they had chronic unspecific low-back pain according to the French health authority (Haute Autorité de santé) that progressed over 3 months; the pain affected professional activities, whether the patient was working, on sick leave or on workers’ compensation due to an occupational accident; conventional therapeutic treatments and outpatient rehabilitation had failed; and the patient was highly motivated for the program with an objective of returning to work and/or resuming sport activities. We excluded all patients with secondary low-back pain (infectious, inflammatory, traumatic, malignant), cardiovascular abnormalities screened during a stress test (performed after age of 50 or presence of cardiovascular risk factors) or psychiatric disorders (taking psychotic drugs) not compatible with program adherence.
Data were collected from charts of all patients who participated in the program. Patients who did not come to the consultation at months 6 and 12 were contacted by phone to collect the relevant data. Data were collected on age, sex, BMI, practice of physical activities before entering the program; clinical elements related to the low-back pain (duration of low-back pain, presence or not of associated disc pain, history of spine surgery, pain measured on a visual analog scale [VAS], analgesic consumption, history of physical therapy in the past 6 months); socio-professional situation; and physical features (Schober’s test, modified Schober’s test, fingertip-to-floor [FTF] distance, popliteal fossa [PF], heel-to-buttock distance [HTB], and flexor endurance tests according to Shirado and trunk extensor tests according to Sorensen).
2.2
Program objectives
Objectives set with the patient the day before the program began were evaluated at 6 months. Nurses from the physical medicine and rehabilitation unit, who were trained in health education needs, performed an individual educational assessment with the patient. This standardized assessment explored the individual context, history of the disease, knowledge, pain evaluation and its impact, patient expectations, consequences of the disease, and coping strategies and life goals of these patients. After this individual interview, therapy objectives were set. The objectives could focus on returning to work, resuming physical activities, or better pain management, and improved body knowledge. At 6 and 12 months, patients were seen again by the nurses to determine whether the objectives were met, not met but attainable, or impossible to meet.
For healthcare professionals, the educational objectives of the program were to progressively expose the patient to previously avoided activities and movements, associated with cognitive training on fears and beliefs; reinforcing adapted behaviors, focusing on preventive attitudes (self-rehabilitation, physical activity, returning to work, proper life habits, relaxation); working on emotional components and enhancing the patient’s feelings of self-efficacy; acquiring self-care and self-management competencies for dealing with a chronic disease (pain management); and reinforcing the acceptance of the chronic pain. Table 1 lists the workshops involved. Documents on low-back pain and a guide with self-help exercises were given to the patient at the end of the program.
| Name of the session and session moderator | Educational objective |
|---|---|
| Muscle tone rehabilitation Physical therapist: 4 h/week | Learning self-rehabilitation techniques |
| Strength-training Physical therapist 4 h/week | Implementing regular physical activity |
| Stretching Physical therapist 2 h 30/week | Learning self-rehabilitation techniques |
| Balneotherapy Physical therapist 2 h/week | Learning self-rehabilitation techniques |
| Yoga Physical therapist 5 h/week | Learning relaxation and self-rehabilitation techniques Establishing a relationship between psychological factors and their physical expression |
| Feldenkrais Occupational therapist 2 h 30/week | Knowing how to move differently without pain |
| Ergonomics Occupational therapist 5 h/week | Working on enhancing knowledge on low-back pain mechanisms, notions of anatomy and spine biomechanics Physical and posture reconditioning |
| Pain Nurse 1 h/week | Understanding the mechanisms of chronic pain Learning to cope with a painful episode Understanding the importance of good life habits |
| Support group Psychologist, physician 1 h 30/week | Establishing a relationship between psychological factors and chronic pain |
| Medical synthesis The entire team 1 h/week | Positive reinforcement |
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