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How to make sense of the placebo effect in clinical practice

Slawomir Wojniusz, Associated Professor at MUSK Health Research Group, OsloMet and Cognitive Health in Trauma and Disease research group, Oslo University Hospital

New insights into the mechanisms behind the placebo effect have led to a growing debate about how it can be exploited in clinical practice. As a consequence, a number of articles recommending ways of utilization of the placebo effect have appeared. This trend raises some important questions: Should we adjust our approaches to facilitate the occurrence of placebo effects? If so, how should we go about doing so? And would doing so even be considered ethical?

Instead of directly answering these questions, I will try to present an alternative look at placebo effects throughout the rest of this text – a view that makes them, in practical terms, uninteresting.

Historical perspective on placebo

The term placebo originates from the Latin verb “placeō”, which means, “I shall please”. In the Encyclopedia of Behavioral Medicine (2013) placebo is defined as:

Any inert substance, procedure, apparatus, or similar, that alone has no effect in the body” [1].

In other words, the placebo relates to all types of interventions that in themselves should have no impact on the course of a patient’s illness.

Before World War II the use of placebo modalities e.g. bread or sugar pills, colored water etc., was common and was not considered problematic or unethical. In 1903, Richard Cabot (1868–1939), a distinguished professor at Harvard Medical School, described the placebo’s influence as follows:

He was brought up, as I suppose every physician is, to use placebo, bread pills, water subcutaneously, and other devices… How frequently such methods are used varies a great deal I suppose with individual practitioners, but I doubt if there is a physician in this room who has not used them and used them pretty often…I used to give them by the bushels” [2].

In that era, the placebo treatment was considered safe, although in medical terms ineffective. It was first and foremost applied to please and comfort the patient in order to“ smooth [the patient’s] path”, especially the “ignorant…disappointed and displeased.. hopeless, [and] incurable case[s]” [3].

The role of placebo started to change in the 1950s. One of the most influential papers on this subject, “The powerful placebo”, was published in 1955 by Henry Beecher, who proposed a new, important role for placebo:

the use of this tool is essential…to distinguish pharmacological effects from the effects of suggestion and….to obtain an unbiased assessment of the result of experiment” [4].

This new view of placebo coincided with massive advances in medicine, just when many incurable diseases were successfully tackled with potent antibiotics and vaccination programs.  A need for systematic evaluation of the efficacy of new drugs was apparent. As a result, the randomized placebo controlled trial became the gold standard for testing the effects of drugs and other treatment modalities. Furthermore, the development of more patient centered and less paternalistic approaches to treatment led to further changes with regards to ethical standards; deceiving the patient through the application of biologically ineffective placebo treatments was no longer considered acceptable. Hence, during the last decades of the 20th century the term ‘placebo’ was reserved either to describe randomized controlled trials or as a derogatory term for postulated effects of alternative or dubious treatment approaches. Many researchers have even denied its existence, explaining the observed effects as part of the natural course of disease, or as regression to the mean and methodological biases, such as unregistered extra treatments received outside the study, or flawed randomization and blinding procedures [2]. The notion that placebo is a form of “cheating” has not disappeared in modern times. It is still present today despite all the new insights into its working mechanisms. Nevertheless, the first decade of the 2nd millennium has brought with it a gradual change when it comes to  how we view placebo effects, as a result of discoveries concerning their neurobiological effects. Today, there is no doubt, that placebo effects elicit specific, psychoneurobiological responses. Here, I will only provide a brief summary of the neurobiological mechanisms behind the placebo effect. For a more detailed description of the involved mechanisms, please see a brilliant article by Testa and Rossettini called “Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes” [5].

A modern era in placebo – neurobiological mechanisms

The majority of the placebo/nocebo research has been concerned with explaining their effects on pain. Recent findings indicate that placebo and nocebo phenomena are closely connected to the activity of the so called Descending Pain Modulatory System (DPMS), the same system that plays a central role in modulation of nociceptive and persistent pain. DPMS acts through a number of neuronal pathways employing different neurotransmitters and neurohormones including endogenous opioids, cannabinoids, dopamine, oxytocin and vasopressin [6, 7]. The DPMS brain regions that are shown to be active in placebo responses include; dorsolateral prefrontal cortex, rostral anterior cingulate cortex, amygdala and periaqueductal gray [8]. The involved brain areas, neurotransmitters and neurohormones are essential in processes related to pain, emotion regulation, reward seeking and social interactions. Furthermore, neuroimaging studies indicate that reduced pain ratings during placebo interventions also coincides with decreased activity in brain areas associated with classical pain processing, and that the pain-related activity in the ipsilateral dorsal horn, corresponding to painful stimulation is reduced under placebo [8]. Placebo effects may also be partially or fully blocked by naloxone, an opioid receptor antagonist, which is  proof of the neurobiological nature of the placebo effect [9].

Although pain has been the main focus of placebo research, the effects are not only limited to pain. For example, in Parkinson patients, increased dopamine production in the striatum was observed in conjunction with placebo treatment, and found to improve the patients’ motor function [10]. Placebo treatment has also been found to influence the immune system and related diseases [11]. Similarly, placebos have also been shown to modulate function of other inner-organs systems, e.g. pulmonary, gastrointestinal and cardiovascular [8].

Overall, the evidence shows that the placebo effect should be understood in a system dynamics perspective, where functioning of many biological and physiological systems in the body is dynamically and simultaneously influenced. Hence, placebo responses represent a complex interplay of biological, physiological, cognitive, emotional, social and environmental factors that need to be accounted for when it comes to explanation and exploitation of placebo responses.

Magic behind a phenomenon that “does not work”

According to its definition, a placebo is a substance, procedure or similar that alone has no effect in the body. Paradoxically, however, this is, a self-contradictory definition since the placebo effect would be an effect of something that “…has no effect in the body”. In practice, it means that the observed effect must be mediated by other processes triggered by the application of a placebo. The single most important message here is that these processes are not specifically dependent on the usage of placebo remedies, but also take place when valid, scientifically proved treatments are applied. In other words, the so-called placebo effects take place independently of whether we use sugar pills or meta-analysis validated, muscle strengthening protocols. Therefore, talking about placebo effects in clinical practice makes little sense. For clinicians, insights from placebo research are important to understand the relationship between, the body, psyche and environment, which will enable us to manipulate contextual factors for the benefit of overall treatment outcomes.

Psychological mechanisms behind the placebo effect/placebo effects

Although neurobiological findings explain the basic mechanisms behind the placebo effect, the psychological aspects of this phenomenon are perhaps even more interesting, as they can be influenced in a therapeutic setting. Most literature identifies two specific psychological mechanisms behind the placebo effect: the first one involves positive expectations towards treatment outcome; the second one is related to learning mechanisms involved in classical conditioning [12].

Positive expectations towards treatment can be induced by verbal instructions and explanations, which is generally known and accepted by health care professionals. However, different contextual factors may additionally influence expectations in an unconscious way, for example, through social observation, e.g. analgesic responses have been shown to occur after subjects have observed other persons undergoing analgesic treatment [13]. Other contextual factors shown to influence placebo responses may include the appearance of health care professionals, medical facilities, treatment tools, smell, color, shape and size of tools and medications, interactions with other people, etc. [14]. Another interesting aspect of this is trying to understand through which psychological mechanisms influencing expectations seem to work. Although research in this area is limited,  four different pathways have been suggested [15]:

  1. Anxiety reduction pathway promoted by clinical communication that contributes to reduction of activity in threat-related centers in the brain.
  2. Positive affectivity pathway, where anticipating a beneficial treatment outcome increases positive feelings stimulating dopaminergic reward mechanisms in the brain.
  3. Interpretative pathway, where expectations modify attention, detection and interpretation of somatic experiences in a non-conscious way.
  4. The associative pathway, where different cues may activate simple previously established associative responses.

Simply put, positive expectations towards treatment may reduce anxiety around the condition, increase positive emotions, e.g. encourage more optimistic views of the future, give hope, strengthen motivation, change cognitions about the condition, reduce attention towards symptoms and so on. In modern medical practice all those “pathways” are in fact already considered important in treating any type of condition and particularly multifactorial and persistent ones. In this respect “the placebo effect/s” is already integrated with modern standards for high quality clinical encounters between patients and health care professionals. The knowledge we gain from the placebo research field can, on the other hand, make us even more aware of how therapy outcomes might be influenced and thus enable us to further optimize the context to achieve maximum gains. It is thus important that the effects of specific procedures, e.g. strengthening exercises, soft tissue treatment, etc., are not viewed independently but in the context of these effects. Although, the quantification of individual contributions of all involved factors is a difficult task, their effects should be seen in a system dynamics perspective; changes in one system may reinforce/multiply the actions of other systems and the other way around. The interdependencies are not limited to the physiological systems alone but have implications for the behavior of the patients that will in turn further influence physiological systems, e.g. reduced anxiety about the condition and positive emotions might influence health related behaviours such as level of physical activity or eating habits.

“Mindset matters” example

The Mindset matters study [16] might be considered as an example of far reaching interdependencies between various physiological systems and behaviour. Eighty-four female room attendants working in seven different hotels were measured on physiological health variables affected by exercise. Those in the informed condition were told that the work they do (cleaning hotel rooms) is good exercise and satisfies the Surgeon General’s recommendations for an active lifestyle. Subjects in the control group were not given this information. After 4 weeks, the informed group showed a decrease in weight, blood pressure, body fat, waist-to-hip ratio, and body mass index. They perceived themselves to be more active than at the baseline but did not in fact report any changes in their actual physical activity levels, e.g. training outside of work.  The authors suggest that the observed physiological changes might be a placebo effect, but it is unclear how these effects were mediated. The design of the study unfortunately does not allow us to draw any meaningful conclusions. However, having a positive mindset and positive emotions might have influenced their stress hormones levels, eating behavior and/or daily activity (e.g. taking the stairs instead of the elevator) and may in this way have impacted body weight and physiological parameters. The study is also a good example of the difficulties one might come across with regards to estimation of the contributions of various contextual factors for overall clinical outcome.

Influencing the context in practical terms

Since many different contextual factors influence the outcome, the question that remains is: how should we employ the knowledge about them in practice? Although some general guidelines are well known, i.e. how to create a positive patient-therapist relationship etc., these only pertain to a small piece of the bigger puzzle. Furthermore, our patients differ a lot and specific recommendations will never be beneficial for all of them. It might therefore be useful to shift our perspective towards a more philosophical level, abstracting the placebo effect away from its neurobiological nature. In 1997, Howard Brody proposed a so-called ‘meaning model’ of the placebo effect/s. In its essence the model suggests that a placebo response  is most likely to occur when the meaning attached to the illness experience is altered in a positive direction [17]. In layman terms, the treatment should make as much sense as possible for the patient. For example, it is not always necessary for the patient to understand every detail of the treatment procedure, or what exactly is going on in the brain during pain modulation. However, the explanation provided and the practical approach should be as meaningful as possible for the patient, eliciting positive emotions and confidence that the treatment works. For some patients a detailed science-based explanation will be appropriate, but for others it might be more meaningful to use a non-scientific metaphor. Furthermore, meaning is also created through non-verbal cues. The model emphasizes the importance of symbols in communication. In that sense, treatment becomes a symbol based ritual. The procedures and artifacts that are associated with good treatment outcomes will thus mobilize self-healing in patients, reinforcing the effect of the treatment. Moreover, the most powerful symbols and rituals will differ between cultures and settings. Using contexts in a way that promotes confidence in the treatment and in the therapist, is therefore an art.  It is, however, a very different art form to that of giving the patient a sugar pill and saying that this is a fantastic new drug. In a clinical context, the usage of placebo remedies is therefore neither necessary nor desirable in order to achieve the desired outcome.

Conclusion

The so-called placebo effect always plays a role in any type of clinical encounter, independently of whether the applied modality is a pure placebo or evidence based. Furthermore, the specific treatment effect and the so-called placebo effect will always interact, and reinforce or diminish each other, and further influence the self-healing process. Separating specific, therapeutic factors from contextual factors effects just does not seem to make sense. We should rather integrate both of them into our approaches in a natural and elegant way promoting the positive meaning of the treatment, e.g. as my old psychiatry professor used to simply put it when addressing his patients: “Antidepressants work, you just need to wish them welcome.”

 

References

  1. Gellman, M.D. and J.R. Turner, Encyclopedia of behavioral medicine. Springer reference. 2013, New York: Springer. 4 volumes.
  2. Kaptchuk, T.J., Powerful placebo: the dark side of the randomised controlled trial. Lancet, 1998. 351(9117): p. 1722-5.
  3. Pepper, O.H.P., A note on placebo. Am J Pharm, 1945. 117: p. 409-412.
  4. Beecher, H.K., The powerful placebo. J Am Med Assoc, 1955. 159(17): p. 1602-6.
  5. Testa, M. and G. Rossettini, Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther, 2016.
  6. Carlino, E. and F. Benedetti, Different contexts, different pains, different experiences. Neuroscience, 2016. 338(Supplement C): p. 19-26.
  7. Finniss, D.G. and F. Benedetti, Mechanisms of the placebo response and their impact on clinical trials and clinical practice. Pain, 2005. 114(1-2): p. 3-6.
  8. Meissner, K., et al., The Placebo Effect: Advances from Different Methodological Approaches. The Journal of Neuroscience, 2011. 31(45): p. 16117-16124.
  9. Amanzio, M. and F. Benedetti, Neuropharmacological dissection of placebo analgesia: expectation-activated opioid systems versus conditioning-activated specific subsystems. J Neurosci, 1999. 19(1): p. 484-94.
  10. Lidstone, S.C., Great expectations: the placebo effect in Parkinson’s disease. Handb Exp Pharmacol, 2014. 225: p. 139-47.
  11. Vits, S., et al., Behavioural conditioning as the mediator of placebo responses in the immune system. Philos Trans R Soc Lond B Biol Sci, 2011. 366(1572): p. 1799-807.
  12. Carlino, E., A. Pollo, and F. Benedetti, Placebo analgesia and beyond: a melting pot of concepts and ideas for neuroscience. Curr Opin Anaesthesiol, 2011. 24(5): p. 540-4.
  13. Colloca, L. and F. Benedetti, Placebo analgesia induced by social observational learning. Pain, 2009. 144(1-2): p. 28-34.
  14. Benedetti, F., Placebo and the new physiology of the doctor-patient relationship. Physiol Rev, 2013. 93(3): p. 1207-46.
  15. Geers, A.L. and F.G. Miller, Understanding and translating the knowledge about placebo effects: the contribution of psychology. Curr Opin Psychiatry, 2014. 27(5): p. 326-31.
  16. Crum, A.J. and E.J. Langer, Mind-set matters: exercise and the placebo effect. Psychol Sci, 2007. 18(2): p. 165-71.
  17. Miller, F.G. and L. Colloca, Semiotics and the placebo effect. Perspect Biol Med, 2010. 53(4): p. 509-16.

 

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How to get people with persistent pain moving

written by Daniel Major, PhD-student and member of the Musculoskeletal Health research group at Oslo and Akershus University College of Applied Sciences 

Movement seems to be one of the few interventions most physiotherapists and other health care providers seems to agree that will most likely be helpful for patients with persistent pain. The last few years there have been written great articles about the potential of movement (or exercises) when treating patients with persistent pain, but how do we get people moving? I do not think I have the definite answer, but I will try to explore some of the literature regarding exercise adherence and provide a brief summary of the strategy I use when trying to get people with persistent pain moving without constant supervision. Exercise adherence seems to be viewed by many therapists as the patients’ responsibility, but to increase exercise adherence I believe we need to take some of the responsibility and facilitate the behaviour change. I believe we need to have comprehensive knowledge about the barriers and facilitators, and learn to incorporate strategies that have the potential of facilitating people with persistent pain to adhere to exercise/movement/physical activity in the long-term.

A Cochrane review concluded that there was moderate evidence to suggest that self-management programmes and the inclusion of interventions based on cognitive and/or behavioural principles could help some groups of people with persistent musculoskeletal pain improve exercise adherence [1]. However, only 18 of the 42 RCTs showed that their interventions successfully enhanced adherence to exercise or physical activity in people with persistent musculoskeletal pain [1]. Incorporating specific adherence enhancing strategies within an exercise programme, including education and behavioural techniques such as positive reinforcement, goal setting, and use of an exercise contract, may be beneficial in increasing exercise adherence for people with persistent musculoskeletal pain [1]. A recent clinical update from Booth et al., [2] wrote “A better understanding of strategies to improve treatment adherence such as goal setting, self‐monitoring and professional feedback is required.”

Everybody knows we should prescribe exercises, but should we start talking more about strategies to increase adherence? Everybody knows that movement is good, but how do we get people with persistent pain moving?

Barriers to exercise adherence and possible strategies to overcome these

We have all heard why people do not exercise. Lack of time, lack of motivation, lack of energy, and that exercise cause pain are some of them [3, 4]. We need to find strategies that can be used to challenge and change these barriers to exercise adherence [3]. We need to define barriers for long-term adherence to exercises (problem definition), suggest solutions to overcome these barriers (generation of possible solutions) and based on shared decision-making we should make action plans that the person in front of you feels confident they will be able to do (solution implementation) [5]. Some examples: If a person says, he/her does not have the time to exercise. We should consider identifying available time slots in their weekly routine. We could also consider incorporating exercise into daily routines. We could recommend walking/bicycling instead of driving to work. If lack of motivation is a barrier, we could discuss the benefits of exercise, and set short- and long-term goals that are tailored to the patient to hopefully increase motivation. To make the exercise program less boring, we could tailor the exercise program to the patient’s personal preferences. If lack of energy to exercise is a barrier, we could discuss that regular exercise will increase energy over the longer term and can improve sleep quality. If pain is a barrier, we could reassure by saying that pain is often felt when people with persistent pain exercise and that this is normal and safe, and that this does not mean that exercise is harmful.

A strategy to increase adherence to exercise/physical activity

Lorig and Holman have provided five core self-management skills which I find very helpful when trying to get people moving: Problem solving, decision making, resource utilization, forming of a patient/health care provider partnership, and taking action [5]. I will try to operationalize how our research group work with these skills when trying to increase adherence to self-managed exercises in our coming Ad-Shoulder trial.

Fig 1: Core self-management skills

Problem solving

During the first session with the physiotherapist the focus will be on actively involve the participant in how to keep a good performance level of exercises or how to improve their ability to exercise. The barriers for a long-term adherence to exercises will be defined (problem definition), concrete solutions to overcome these barriers will be suggested (generation of possible solutions), and a brief set of maximum three exercises (because of higher odds of adherence [6]) for the coming week will be agreed upon (solution implementation).

Decision making

During the second session the decision making process will be the main focus. The experiences from the first week will be used to go into a more thorough discussion around how to implement a behaviour in line with adherence to shoulder exercises. For example, the physiotherapist might consider that the participant needs more knowledge in order to meet the goal of long-term adherence to shoulder exercises. This can be related to topics such as how to deal with pain during or after the exercises, what is the optimal dosage of exercises/physical activity, and/or how to deal with pain catastrophizing related to exercises and physical activities. The topic can also be how to organize the daily life in order to prioritize the shoulder exercises.

Example: If pain is experienced whilst exercising the participant will be told that as a rule of thumb it should be no worse upon cessation and should be returned to the pre-exercise level after 24 hours. The participant will also be encouraged to judge what is manageable/acceptable. If the participant experiences unmanageable pain during or after the exercise sessions, they will be advised to cut back on the exercise dosage and try to find a comfortable exercise level, stick to this for 1 or 2 weeks, and add to it by 10 to 20% every 7 to 14 days.

Resource utilization

This skill is related to teaching people how to use resources. Self-management includes helping people seek these out from many sources. For this specific study, we will encourage the participant to identify beneficial resources in their local environment, such as a local gym where they can exercise. Information resources about pain will also be utilized.

Forming of a patient/health care provider partnership

The forming of a participant/physiotherapist partnership will include shared goal setting based on patients’ personal preferences by using the Patient Specific Function Scale [7], and collaborative problem solving. To strengthen the patient-therapist interaction we will allow patients to tell their story, provide emotional support, chat with the patient in a friendly manner and to motivate and show encouragement [8].

Taking action

Taking action reflects skills that are involved in learning how to change a behaviour. An action plan for the next 1-3 weeks will be worked out, together with the patient. The action plan will contain information about the time points for exercises and/or other physical activities, the amount (number and length of sessions) and self-managed modifications of the plan. Pain intensity during the last week will be used as an indicator for progression or regression of the program. Pain which is manageable, will be allowed during and after exercises. Advice in relation to progression and regression of exercises, will be provided; this may include adjusting the volume of exercise sessions, resistance of exercises (weight), number of repetitions and/or change the type of exercises. The adjustment of the exercises program is an integrated part of the problem solving- and decision making skills.  In relation to self-management theory, the actions need to reflect something that the participant is fairly confident to accomplish. Level of confidence will be measured by asking the patient how confident they are that they will do the exercise program according to the short-term goal. The participant will score their level of confidence on a numerical rating scale from 0 (totally unconfident) to 10 (totally confident). If the answer is 7 or higher, based on self-efficacy theory, there is a good chance that the action plan will be accomplished. If the answer is less than 7, the physiotherapist will encourage to further problem solving in order to make the plan more realistic and to avoid failure.

During the last individual sessions, a long-term action plan will be developed together with the patient. In this plan, physical activities that may replace or supplement the exercise program, is discussed. This plan will strongly be tailored to the individual and the patient should be encouraged to continue an active-lifestyle in relation to physical activity involving a varied use of the upper-extremities. This plan will be evaluated in two telephone follow-up conversations, where there is room for problem solving if needed.

Joyful activities (in my opinion) that involves a varied use of the upper-extremities. Photos: Daniel H. Major and Yngve Røe

 

Hope you will give this strategy a go. It has made me more confident and strategic when trying to get people with persistent pain moving on their own and I have seen good results (level 5 evidence/”anecdata”). However, a similar intervention has yielded promising results in a Randomized Controlled Trial and has been shown to be equally as effective as usual care among patients with rotator cuff tendinopathy [9]. In the future, our research team will hopefully be able to test this self-management intervention for patients with subacromial pain/rotator cuff tendinopathy/non-specific shoulder pain in a randomised controlled trial.

References

  1. Jordan JL, Holden MA, Mason EE, Foster NE: Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010(1):Cd005956.
  2. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M: Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care 2017:n/a-n/a.
  3. Bennell KL, Dobson F, Hinman RS: Exercise in osteoarthritis: moving from prescription to adherence. Best Pract Res Clin Rheumatol 2014, 28(1):93-117.
  4. Dobson F, Bennell KL, French SD, Nicolson PJ, Klaasman RN, Holden MA, Atkins L, Hinman RS: Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis: Synthesis of the Literature Using Behavior Change Theory. American journal of physical medicine & rehabilitation 2016, 95(5):372-389.
  5. Lorig KR, Holman H: Self-management education: history, definition, outcomes, and mechanisms. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 2003, 26(1):1-7.
  6. Medina-Mirapeix F, Escolar-Reina P, Gascon-Canovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM: Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC musculoskeletal disorders 2009, 10:155.
  7. Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M: The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction. Physical therapy 1997, 77(8):820-829.
  8. O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, O’Sullivan K: What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical therapy 2016, 96(5):609-622.
  9. Littlewood C, Bateman M, Brown K, Bury J, Mawson S, May S, Walters SJ: A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study). Clin Rehabil 2016, 30(7):686-696.

 

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An overview of three recent biopsychosocial treatment models for musculoskeletal pain disorders

Yngve Roe1 and Daniel Major2  

  1. Associated professor, Institute of Physiotherapy, Oslo University College of Applied Sciences (HIOA) and clinical physiotherapist; e-mail: Yngve.roe@hioa.no
  2. PhD Research Fellow, Institute of Physiotherapy, Oslo University College of Applied Sciences (HIOA) and clinical physiotherapist; e-mail: daniel-hogli.major@hioa.no

 

The increasing disability caused by musculoskeletal pain disorders such as back-, neck- and shoulder pain is a global challenge (Vos et al., 2012). This development put strain on health care systems, as they need to address rising numbers of patients with conditions that largely cause disability but not mortality (Vos et al., 2012).

Within rehabilitation, common treatments for persistent musculoskeletal pain disorders are surgery, injections, physiotherapy and/or medication. Among physiotherapists, exercises alone, or in combination with manual therapy is the most common treatment intervention. Often exercise treatment for patients with musculoskeletal disorders are based on a structural model, aiming to increase strength and load tolerance in local tissue, such as muscles, tendons and ligaments. In these types of treatment models, thoughts and experiences of the patients about pain and movement, are redundant. The role of the physiotherapist is to teach and educate the patient in exercises and physical activity. Actually, this professional role can be quite pleasant for both sides; the patient may have an experience of getting clear answers about their condition and the physiotherapist thinks their knowledge and skills, are utilized. In other words, both parts are satisfied! But the question remains; does it work? At the societal level, based on the high and increasing burden of musculoskeletal disorders, the answer is no. At the level of the patients, a number of systematic reviews have found low to moderate short term benefits on pain, but not long term effect on disability. The dominant pathoanatomical treatment model for persistent musculoskeletal pain, is increasingly challenged among researchers in physiotherapy, in particular within the field of back pain (P. O’Sullivan, 2012).

With the growth of the biopsychosocial model of disability and recent advances in pain research, several new exercise treatment models for persistent pain conditions, have been developed. According to the International Association for the Study of Pain (IASP) pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Patients with persistent musculoskeletal pain can have remarkably similar pathology but dissimilar clinical presentations encompassing different thoughts, beliefs, behaviours and expectations which require different exercise treatment approaches (Booth et al., 2017). This has led to an increased attention on screening for psychological factors (yellow flags) (George & Stryker, 2011; Main & George, 2011; Nicholas & George, 2011). However, physiotherapist does not always provide treatments that underpin this definition and many focus solely on the biomedical model biased by their professional backgrounds, beliefs and training, and remain in their “comfort zone”, without exploring other domains (K. O’Sullivan, O’Sullivan, Vibe Fersum, & Kent, 2016).

As a result of the introduction of the International Classification of Functioning, disability and Health in 2001, a new biopsychosocial framework for functioning, is available. Following this, a number of condition-specific ICF categories, which describes common impairments, limitations and restrictions in musculoskeletal disorders, has been identified. This most rapid development, again, is within low back pain, were a comprehensive ICF core set, is available (Cieza et al., 2004). However, also within shoulder pain, patient experiences within the ICF framework, has been investigated (Roe, Bautz-Holter, Juel, & Soberg, 2013). This research confirms that there are large commonalities in relation to the disability, across conditions (Schwarzkopf et al., 2008).

Based on the developments within pain and disability research on persistent musculoskeletal disorders, we believe it is unfortunate that much of the research still is divided in separate fields, such as back-, knee- and shoulder research. Advance within one of these fields, seems to have little or no impact in another. An explanation for this, can be that among health professionals, there are beliefs that these conditions should be treated differently. For example, in discussions of pain in relation to exercise performance, among some physiotherapists it is believed that pain in the lower extremities is more acceptable than shoulder and elbow pain during exercises. This opinion (by a leading physiotherapist in elbow rehabilitation) was justified by arguing that the motor performance of the upper-extremity is different. In our opinion, such beliefs, that whatsoever have no theoretical foundations, contribute to consolidate the barriers between rehabilitation fields.

Recent, biopsychosocial treatment models for physiotherapy have the potential to enhance rehabilitation for patients with persistent pain. In this development, researchers such as Peter O’Sullivan and Kieran O’Sullivan have made major contributions, with the development of Cognitive Functional Therapy for back pain. Their impact has both been due to the quality of their research and their willingness to engage on social media. In shoulder pain rehabilitation, Chris Littlewood has made similar contributions, with the development of a self-management model. Within the field of pain research, Jo Nijs, has established a framework for cognition-targeted exercise therapy, hereafter referred to as the pain memory model. As mentioned, knowledge-transferal across rehabilitation fields, are limited. The purpose of this paper was to investigate similarities and differences between these three exercise models for persistent musculoskeletal pain. The more specific aim was to investigate the theoretical underpinnings of these models and how they deal with symptoms during treatment.  

 

Similarities and differences between three exercise treatment models for persistent musculoskeletal pain   

All three treatment models have in common that they are underpinned by psychological theory. Both the cognitive functional therapy- and the pain memory models, have referral to Cognitive Behavioural Therapy (CBT); however the pain memory model have more explicit referrals to acceptance, commitment theory, which has gained increasing popularity in a number of fields in the last years. In contrast, Self-Managed Exercises have referral to Social Cognitive Theory (SCT). SCT has been closely linked to behavioural change, based on the work of psychologists such as Albert Bandura (Bandura, 1977). The principles of SCT has been applied on different educational situations such as increasing fruit and vegetable intake, increasing physical activity, HIV education, and breastfeeding. Enhancing patient’s self-efficacy, which is seen as a mediating factor, is considered a premise for behavioural change. Principles for how this can be operationalized within a treatment context, has been provided by Lorig & Holman, who has suggested five core self-management skills that should be addressed: problem solving, decision-making, how to utilize resources, forming partnerships with health care providers and taking action (Lorig & Holman, 2003).  

Physical activities and exercises can be painful and it is often difficult to advice patients in relation to these symptoms. For patellofemoral pain syndrome it has been suggested that VAS pain level up to 5 during exercise, is acceptable (Thomee, 1997). In line with this, Silbernagel & Crossley proposed a pain monitoring model where 0-2 was “safe zone”, 2-5 “acceptable zone” and 5-10 “high risk zone” (Silbernagel & Crossley, 2015). Another common pain monitoring model presented by Moseley, suggest that some pain during activity is acceptable, but it should stay under the point of a «flare up» (Moseley, 2003). None of the three treatment models we analysed, use a rigid VAS- or numerical pain monitoring model. However, some interesting differences between the models, were identified: the pain memory model emphasizes that exercises should be time contingent. This can be interpreted as acceptance of higher levels of pain, where pain shall not determine the number of repetitions or exercise duration. According to the model, the emotional response (fear) of the exercise, is the deciding factor. The cognitive functional therapy model emphasizes that exercises should aim at normalising maladaptive and provocative postural movement behaviours as directed by the patient’s individual presentation. Thus, the focus rather is on the quality of the motor performance. This is a view that is probably recognized by a majority of physiotherapists – sometimes pronounced as relearning of normal movement patterns. Nevertheless, the concept of normal, adaptive, non-normal or maladaptive is based on empirical, rather than theoretical evidence. In addition, there is always a balance in patient communication between enhancing patients’ self-efficacy and introducing concepts of normal and maladaptive movement. The last model, self-managed exercises, has a slightly different approach to pain-management, as it enables the patient to judge what is tolerable in terms of symptom response, although the pain should be no worse upon cessation.

All three models seem to have in common that pain during exercises not only is something that should be controlled, but also actively approached. For example, in the self-management model, exercises are chosen, because they trigger pain. Furthermore, if the pain response abates this is the stimulus to progress the exercise. In our view, several topics should be discussed in relation to the pain monitoring in the three models, such as: Are there no limits for pain intensity during exercising as long as there is little emotional response? What is the evidence for maladaptive movements and is it different between body parts? Is it beneficial to use pain as the deciding factor in selecting and progressing exercises?   

Behavioural change in relation to increased physical activity should be a long term aim of interventions for patients with persistent musculoskeletal pain. Both the Cognitive Functional Therapy model and the self-managed exercises have explicitly outlined this. However, in the Cognitive Functional Therapy model, there is little referral to a methodological approach to behavioural changes. Instead, physical activity and lifestyle training is a step, following cognitive training, movement training and functional integration. In contrast, change in behaviour is a major focus in the self-management model. As earlier discussed, change in behaviour is underpinned by Social Cognitive Theory and decades of empirical evidence. However, in the self-managed exercise model, goal-setting is linked to patient-reported limitations in performing activities and not to physical activities and lifestyle changes. This is consistent with the functional integration step in the Cognitive Functional Therapy model. It is reasonable to question whether the self-managed exercise intervention sufficiently fills the gap between activity performance and changes in lifestyle behaviour. Progression in this model is rather linked to pain intensity than lifestyle behaviour. The latter model, pain memory, does not cope with physical activity and lifestyle behaviour. In our view, this point at an important issue within physiotherapy; what is the ultimate aim for interventions? To increase patients’ capabilities or actual performance to execute activities, or physical activity? There is no straight forward answer to this question, but in our opinion physiotherapy as a profession historically has been little focused on discussing these questions.  

The three treatment models we have presented, represent important progress within the field of physical therapy. Biopsychosocial models for treatment will hopefully progress in the forthcoming years, with further refinement of existing models and introduction of new. To achieve this, in our view three factors are crucial: Firstly, transition of knowledge between clinical fields. Why do back- and shoulder pain researchers go to different congresses? Secondly, we think there is a potential to improve how treatment interventions are anchored to theory and empirical research. Thirdly, there still is a potential to tailor interventions to the patients experiences of living with persistent pain.

Patients with persistent musculoskeletal disorders need high quality health care. It is our hope and belief that physiotherapy as a profession will contribute to enhance treatment interventions which systematically addresses patients’ fear, worries, hopes for the future, self-efficacy and helps them to become more active and resilient. In the wise words of the late, great Louis Gifford: «Physiotherapy is about the restoration of thoughtless, fearless and painless movement».

 

 

Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215.

Booth, J., Moseley, G. L., Schiltenwolf, M., Cashin, A., Davies, M., & Hübscher, M. (2017). Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care, n/a-n/a. doi:10.1002/msc.1191

Cieza, A., Stucki, G., Weigl, M., Disler, P., Wilfried, J., van der Linden, S., . . . de Bie, R. (2004). ICF Core Sets for low back pain. Journal of Rehabilitation Medicine(44 Suppl), 69-74.

George, S. Z., & Stryker, S. E. (2011). Fear-avoidance beliefs and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain conditions. The Journal Of Orthopaedic And Sports Physical Therapy, 41(4), 249-259. doi:10.2519/jospt.2011.3488

Lorig, K. R., & Holman, H. (2003). Self-management education: history, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26(1), 1-7.

Main, C. J., & George, S. Z. (2011). Psychologically Informed Practice for Management of Low Back Pain: Future Directions in Practice and Research. Physical Therapy, 91(5), 820-824. doi:10.2522/ptj.20110060

Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140. doi:10.1016/S1356-689X(03)00051-1

Nicholas, M. K., & George, S. Z. (2011). Psychologically Informed Interventions for Low Back Pain: An Update for Physical Therapists. Physical Therapy, 91(5), 765-776. doi:10.2522/ptj.20100278

O’Sullivan, K., O’Sullivan, P., Vibe Fersum, K., & Kent, P. (2016). Better targeting care for individuals with low back pain: opportunities and obstacles. Br J Sports Med. doi:10.1136/bjsports-2016-096612

O’Sullivan, P. (2012). It’s time for change with the management of non-specific chronic low back pain. British Journal of Sports Medicine, 46(4), 224-227.

Roe, Y., Bautz-Holter, E., Juel, N. G., & Soberg, H. L. (2013). Identification of relevant International Classification of Functioning, Disability and Health categories in patients with shoulder pain: A cross-sectional study. Journal of Rehabilitation Medicine, 45(7), 662-669. doi:10.2340/16501977-1159

Schwarzkopf, S. R., Ewert, T., Dreinh, x00F, fer, K. E., Cieza, A., & Stucki, G. (2008). Towards an ICF Core Set for chronic musculoskeletal conditions: commonalities across ICF Core Sets for osteoarthritis, rheumatoid arthritis, osteoporosis, low back pain and chronic widespread pain. Clinical Rheumatology, 27(11), 1355-1361.

Silbernagel, K. G., & Crossley, K. M. (2015). A Proposed Return to Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. J Orthop Sports Phys Ther, 1-42. doi:10.2519/jospt.2015.5885

Thomee, R. (1997). A comprehensive treatment approach for patellofemoral pain syndrome in young women. Phys Ther, 77(12), 1690-1703.  

Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., . . . Memish, Z. A. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380(9859), 2163-2196. doi:10.1016/S0140-6736(12)61729-2

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Is it time for change with the management of chronic shoulder pain?

Daniel Major is working as a PhD-student at the Oslo and Akershus University College. His main area of research is self-managed exercise interventions for shoulder pain. Daniel is also an experienced clinician and has been a leader of the outpatient clinic at the Institute of Physiotherapy. Finally, Daniel is a king of social media, running the Facebookgroup Major Fysioterapi

 

In this post, I will try to provide brief answers to some questions I often get and I believe are important related to treatment of patients with chronic shoulder pain. I will try to elaborate with some of my thoughts regarding possibilities of the enhancement of physiotherapy treatment for people with chronic shoulder pain. These thoughts are based on my experience as a physiotherapist and the massive amount of research I have been reading the past year when preparing for the start of my PhD journey.

How common is shoulder pain and what is the cost-of-illness?

Shoulder pain is common, with a point prevalence ranging from 7 to 26% in the general population [1]. A Swedish cost-of-illness study revealed that the mean healthcare cost per patient was €326 (SD 389) during six months, where physiotherapy treatments accounted for 60% [2]. The mean annual total cost was €4139 per patient and the costs for sick leave contributed to 84% of the total costs [2].

What is the most effective treatment intervention for patients with chronic shoulder pain? Physiotherapy (active exercises) or surgery (arthroscopy)?

To answer big questions like this one, I prefer reading systematic reviews with a meta-analysis. Different studies often reach different conclusions, which could be caused by methodological weaknesses. Saltychev et al., published a systematic review and meta-analysis in 2015, where active exercises and arthroscopy was compared for patients with “shoulder impingement” (also known as subacromial pain, rotator cuff tendinopathy, rotator cuff related shoulder pain, non-specific shoulder pain) [3]. Based on seven randomised controlled trials (RCTs) there is moderate evidence that surgery and active exercises are equally as effective in reducing pain intensity among patients with subacromial pain. This was also the conclusion from Brox et al’s RCT, published in BMJ already in 1993 [4]. Saltychev et al., conclude that because surgery is associated with higher cost and a higher risk for complications, physiotherapy should be the first choice for patients with “shoulder impingement” [3]. About 2 ½ years ago, Professor Jens Ivar Brox told the Norwegian media (tv2) that about 90 percent too many patients with shoulder pain are undergoing surgery. He also said that for 90 percent of the patients active exercises might be sufficient. Despite the evidence, the number of shoulder surgeries are increasing [5, 6].

For how long should patients do active exercises before surgery is considered?

I often hear that patients with shoulder pain should try physiotherapy for 3 months before they get surgery. This wording is a little provocative to me as a physiotherapist, because some patients interpret this into that physiotherapy is something they try, before they get the “gold standard”/surgery. As previously described, surgery is not the gold standard. I also think we should question whether 3 months is enough to reduce pain and increase function. When reading studies I often see that there is a further positive change in function and pain measures from 3-6 months. In both Ketola et al., [7] and Bennell et al., [8] the results show this trend, and when looking at Ketola et al’s two year follow-up the change in the outcome measures continues to improve [7]. Therefore, I think we should consider extending the period with active exercises to a minimum of 6 months. However, this does not imply that the patients will have to do supervised physiotherapy for 6 months, but I believe that they should do exercises up to 6 months and preferably continue doing some exercises or general movement, which includes their upper extremities.

If physiotherapy does not work, does surgery work?

Ketola et al., published a subanalysis in 2015 [9], which provided many interesting findings. In this study the authors questions whether surgery will work, if physiotherapy does not. Eighteen patients in the active exercise group were not satisfied with the results and crossed over to surgery. These patients, did however sadly not improve with this intervention either. The authors state that it seems that 1/3 of the patients does not improve with any form of treatment. So, which factors appears to increase the risk of persistent pain? In this study [9] the duration of symptoms, marital status (single), and lack of professional education appeared to increase this risk. There was also a negative correlation between satisfaction at work and the perception of pain [9].

Which role does expectations have regarding the patient’s “choice of treatment” and the benefit of treatment?

In a study from Dunn et al., [10] it is shown that within patients with full thickness rotator cuff tears, the decision to undergo surgery is more influenced by low expectations regarding physiotherapy than anatomical features of the of the rotator cuff tear. A large multicentre cohort study (n = 1030) from the UK [11] has also shown that positive expectations regarding the physiotherapy treatment is significantly and positively associated with the outcome. It is therefore important to address the patient’s expectations and it must be our job to clarify their expectations and to assist them in having appropriate expectations of recovery [12]. In my opinion, we need to build a strong patient-therapist relationship as a fundament for this journey, which might also increase the patients’ expectations, and has been shown to have a positive effect on treatment outcome [13, 14].

Is there an optimal exercise program for patients with chronic shoulder pain?

There is to my knowledge, no consensus regarding this question in the literature and no optimal dose to apply to all patients, but it seems that exercises that includes resistance might be an important component [15]. To me this is not shocking, even though it used to annoy me when I was a student and had very little experience treating patients. One-size-fits-all models rarely works, when treating people with multidimensional problems like chronic shoulder pain. There are also some results that show that the amount of exercises influences the patients’ adherence [16]. Maybe we should start with 2-3 meaningful exercises, and gradually progress, change and add on to the exercise program based on the patients’ response. The best exercise is often the exercise that you do. If a patient with chronic shoulder pain presents with fear-avoidance behaviour, maybe we should start with providing pain neuroscience education and graded exposure to these exact movements and make use of cognition-targeted exercise therapy as described by Nijs et al., [17]. Based on self-management literature [18, 19] it is important to make a detailed action plan, which the patient believe they will be able to do and provide active follow-up. If the patients does not believe they will be able to adhere to the action plan and/or are having problems adhering to the action plan, it is wisely to do some problem solving with the patient and provide a revised action plan.

Which modifiable factors are associated with a positive outcome?

Higher pain self-efficacy has been shown to be associated with a positive outcome for patients with shoulder pain [11]. In my opinion, we should therefore focus on knowledge translation and effective reassurance to build resilience and provide the patient with active coping strategies, using self-management strategies. Self-efficacy has also been shown to be an important predictor for the patients’ adherence to home based exercises [16]. Findings from chronic low back pain research suggests that pain management and rehabilitation programs should specifically target pain self-efficacy as a key aspect of treatment [20].

It has been shown that active exercises (physiotherapy) has a similar effect to surgery to a fraction of the cost for patients with subacromial pain [3]. It will be very interesting to see the results from the placebo controlled “The CSAW Study” (Can Shoulder Arthroscopy Work) [21]. If surgery ends up being as “effective” as sham surgery, it is my opinion that we as physiotherapist, who provide exercise treatment will also need to consider a change in our management, considering that active exercises is equally as effective as surgery.

Professor Peter O’Sullivan wrote the brilliant editorial; “It’s time for a change in management of non-specific chronic low back pain” in 2011 [22]. I believe it’s time for a change in management of non-specific chronic shoulder pain. It is time to move away from the purely pathoanatomical treatment, which in my opinion has been dominant in management of chronic shoulder pain. In a high quality RCT, a standardised manual therapy and home exercise program has not been shown to provide clinical important differences in comparison with a placebo intervention (inactive ultrasound therapy and application of an inert gel) [8, 23].  If it is the psychological factors that are most strongly associated with a positive/negative outcome [11], maybe we should try modifying these factors? I do not believe these are targeted with an approach that solely focuses on force couples, scapula dyskinesis and posture, which according to the literature is less important than many seems to believe [24, 25]. A Norwegian RCT by Fersum et al., has shown superior outcomes of a classification-based cognitive functional therapy for non-specific low back pain when compared with traditional manual therapy and exercise [26]. Is it time to try something similar when treating patients with chronic shoulder pain?  I think shoulder researchers and clinicians should get inspired by the work of international leading low back pain researchers, who have acknowledged that the patients often present with a complex interaction of biopsychosocial factors and suggests that our treatment needs to reflect this [27-29]?

Refererences:

  1. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA: Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol 2004, 33(2):73-81.
  2. Virta L, Joranger P, Brox JI, Eriksson R: Costs of shoulder pain and resource use in primary health care: a cost-of-illness study in Sweden. BMC musculoskeletal disorders 2012, 13:17.
  3. Saltychev M, Aarimaa V, Virolainen P, Laimi K: Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disability and rehabilitation 2015, 37(1):1-8.
  4. Brox JI, Staff PH, Ljunggren AE, Brevik JI: Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ (Clinical research ed) 1993, 307(6909):899-903.
  5. Thorpe A, Hurworth M, O’Sullivan P, Mitchell T, Smith A: Rising trends in surgery for rotator cuff disease in Western Australia. ANZ journal of surgery 2016, 86(10):801-804.
  6. Judge A, Murphy RJ, Maxwell R, Arden NK, Carr AJ: Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. The bone & joint journal 2014, 96-b(1):70-74.
  7. Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, Arnala I: No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone & joint research 2013, 2(7):132-139.
  8. Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, Forbes A, Buchbinder R: Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ (Clinical research ed) 2010, 340:c2756.
  9. Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Arnala I: Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment? Acta orthopaedica 2015, 86(6):641-646.
  10. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Harrell F, Holloway BG et al: 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg 2016, 25(8):1303-1311.
  11. Chester R, Jerosch-Herold C, Lewis J, Shepstone L: Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British journal of sports medicine 2016.
  12. 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. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne 2001, 165(2):174-179.
  13. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML: The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy 2010, 90(8):1099-1110.
  14. O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, O’Sullivan K: What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical therapy 2016, 96(5):609-622.
  15. Littlewood C, Malliaras P, Chance-Larsen K: Therapeutic exercise for rotator cuff tendinopathy: a systematic review of contextual factors and prescription parameters. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation 2015, 38(2):95-106.
  16. Medina-Mirapeix F, Escolar-Reina P, Gascón-Cánovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM: Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC musculoskeletal disorders 2009, 10(1):155.
  17. Nijs J, Lluch Girbes E, Lundberg M, Malfliet A, Sterling M: Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy 2015, 20(1):216-220.
  18. Lorig KR, Holman H: Self-management education: history, definition, outcomes, and mechanisms. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 2003, 26(1):1-7.
  19. Battersby M, Von Korff M, Schaefer J, Davis C, Ludman E, Greene SM, Parkerton M, Wagner EH: Twelve evidence-based principles for implementing self-management support in primary care. Joint Commission journal on quality and patient safety 2010, 36(12):561-570.
  20. Skidmore JR, Koenig AL, Dyson SJ, Kupper AE, Garner MJ, Keller CJ: Pain self-efficacy mediates the relationship between depressive symptoms and pain severity. The Clinical journal of pain 2015, 31(2):137-144.
  21. Beard D, Rees J, Rombach I, Cooper C, Cook J, Merritt N, Gray A, Gwilym S, Judge A, Savulescu J et al: The CSAW Study (Can Shoulder Arthroscopy Work?) – a placebo-controlled surgical intervention trial assessing the clinical and cost effectiveness of arthroscopic subacromial decompression for shoulder pain: study protocol for a randomised controlled trial. Trials 2015, 16:210.
  22. O’Sullivan P: It’s time for change with the management of non-specific chronic low back pain. British journal of sports medicine 2011.
  23. Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, Mrocki MA, Buchbinder R: Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev 2016(6):Cd012224.
  24. Bury J, West M, Chamorro-Moriana G, Littlewood C: Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: A systematic review and meta-analysis. Manual therapy 2016, 25:35-42.
  25. Barrett E, O’Keeffe M, O’Sullivan K, Lewis J, McCreesh K: Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual therapy 2016, 26:38-46.
  26. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvale A: Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. European journal of pain (London, England) 2013, 17(6):916-928.
  27. O’Sullivan K, O’Sullivan P, Vibe Fersum K, Kent P: Better targeting care for individuals with low back pain: opportunities and obstacles. British journal of sports medicine 2016.
  28. O’Sullivan P, Caneiro JP, O’Keeffe M, O’Sullivan K: Unraveling the Complexity of Low Back Pain. The Journal of orthopaedic and sports physical therapy 2016, 46(11):932-937.
  29. Maher C, Underwood M, Buchbinder R: Non-specific low back pain. Lancet 2017, 389(10070):736-747.
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Veiledet selvtrening, fysioterapi og atferdsendringer

Muskelskjelettlidelser er den største årsaken til helsetap i Norge og de fleste andre vestlige land [1, 2]. Forskning basert på Hunt-undersøkelsen i Nord Trøndelag viser at fysisk inaktivitet er assosiert med økt risiko for muskelskjelettlidelser. Muskelskjelettlidelser utgjør en høy andel av pasientpopulasjonen hos fysioterapeuter i primærhelsetjenesten. Den behandlingsformen som er best kunnskapsforankret er øvelser og fysisk aktivitet. Ikke sjelden er totalantallet og frekvensen på de individuelle konsultasjonene høyt. Målet for behandlingene er typisk å redusere smerte og bedre funksjon. Det tas for gitt at dette vil medføre en mer aktiv atferd hos pasientene. Dette er det grunn til å stille spørsmål ved. Det er kanskje heller ikke å forvente, den tid fysioterapeutene ikke har en bevisst og metodisk tilnærming til atferdsendringer. Stikkord er problemløsningsstrategier og mestring.

Forskningslitteraturen om self-management i forbindelse med behandling av langvarige smertetilstander er stor. Self-managent kan defineres som individets evne til å håndtere symptomene, behandling, fysiske og psykososiale konsekvenser og livsstilsendringer som hører sammen med å leve med en kronisk lidelse [3]. Videre slås det fast at en forutsetning for effektiv veiledet selvhjelp er at den må omhandle evne til å registrere ens tilstand og å påvirke de kognitive, atferdsmessige og emosjonelle svarene som er nødvendig for å opprettholde en tilfredsstillende livskvalitet [3]. På norsk har dette begrepet flere oversettelser, avhengig av kontekst og profesjonsbakgrunn. I en fysioterapikontekst synes jeg veiledet selvtrening er en god oversettelse, som jeg i det følgende vil bruke. Veiledet selvtrening skiller seg fra adherence som forstås som en automatisert oppfølging (for eksempel av retningslinjer).

Hvordan kan fysioterapeuter bedre legge til rette for at pasientene skal endre atferd med tanke på fysisk aktivitet. En av pionerene på self-management, professor Kate Lorig, har foreslått at behandlinger med fokus på veiledet selvtrening må adressere fem sentrale ferdigheter: Problemløsning, beslutningstaking, ressursutnyttelse, utvikling av et pasient- terapeutsamarbeid og iverksettelse av en handlingsplan [4]. Innenfor hver av disse ferdighetene er det trolig mulig å utarbeide fysioterapibehandlinger som er rettet mot øvelser og fysisk aktivitet. Den siste ferdigheten som Lorig foreslår, handlingsplan (taking action), er svært interessant fra et fysioterapisynspunkt. Innenfor denne retningen forstås en tiltaksplan (action plan) som noe som involverer en tidsperiode på 1 – 2 uker og er svært konkret og realistisk. Tiltaksplanen er dermed en konkretisering av de øvelsene og den fysiske aktiviteten du og pasienten har blitt enige om i denne tidsperioden. Basert på de andre nevnte ferdighetene, skal pasienten gjøres rustet til å foreta justeringer av opplegget, basert på de symptomene han/hun kjenner. På forhånd kan pasientens tillit til om han/hun kan gjennomføre tiltaksplanen skåres på en numerisk skala fra 0 (ingen tillit) – 10 (full tillit). Basert på teori om mestringstro (self-efficacy), gir en skår på 7 eller høyere grunn til å tro at pasienten klarer å gjennomføre tiltaksplanen [4]. Er skåren lavere enn 7, bør det fokuseres på strategier i forhold til problemløsning og beslutningstaking.

surflof

Surfing i lofoten (Foto: Mats Grimsæth og Emil Kjos Sollie)

Veiledet selvtrening har i løpet av de siste tiårene endret seg fra rent didaktiske tilnærminger til mer involverende behandlingstilnærminger som er inspirert av klinisk psykologi og kognitiv atferdsteori [5]. Begrepet self-efficacy (norsk: mestringstro) er sentralt innenfor denne retningen. Self-efficacy blir ansett som en medierende faktor for utfallet (for eksempel adherence og bedret funksjon). Denne måten å forstå behandling på, har som konsekvens at fysioterapeuten må gi slipp på ekspertrollen til fordel for en mer samarbeidsorientert tilnærming med problemløsningsstrategier og mestringsevne.

En oversiktsartikkel fra 2010, foreslår tolv kunnskapsbaserte prinsipper for å implementere veiledet selvhjelpsbehandlinger i primærhelsetjenesten [6]. Disse såkalte prinsippene er i stor grad sammenfallende med de ferdighetene Lorig refererte til. Interessant er aktive oppfriskningsbehandlinger et av de prinsippene som foreslås.

Litteraturen knyttet til veiledet selvhjelp er slik jeg ser det svært interessant for fysioterapeuter som arbeider med langvarige smertetilstander. Det er indikasjoner på at tiltak som har en metodisk og systematisk tilnærming til disse ferdighetene, gir atferdsendringer hos pasientene [3]. Det er grunn til å tro at slik behandling har større nytteverdi både for den enkelte og gir bedre ressursutnyttelse for samfunnet. I den såkalte primærhelsetjenestemeldingen tas det til orde for dette, både i forbindelse med brukermedvirkning (s.46) og under diskusjon om utnyttelse av (fysioterapi)ressursene (s.109) [7]. Det er viktig at fysioterapiutdanningene og det kliniske feltet i større grad tar dette innover seg. Faglig sett, understøttes veiledet selvtrening av klinisk forskning som tyder på at mengde øvelser og motstand på bevegelsene er viktigere enn at pasienten utfører øvelsene i overenstemmelse med en norm.

Foto: Yngve Røe

Geir Harald Samuelsen på For lukkede dører 9-/9 i Sørkedalen (Foto: Yngve Røe)

For kommunene er det et problem at tilgangen til prioriterte pasientgrupper er for dårlig hos avtalefysioterapeuter [7]. Viktige årsaker dette er trolig finansieringssystemet (enkelte diagnosegrupper som har krav på fri behandling) og tidkrevende behandlingstiltak med mange konsultasjoner. Utfordringene knyttet til finansieringssystemet kan bli redusert i forbindelse med neste års statsbudsjett, der retten til fri behandling blir kraftig innskrenket. Når det gjelder tidkrevende behandlingstiltak, er det dessverre lite som tyder på snarlige endringer blant fysioterapeutene. For mange sitter det langt inne å gi slipp på ekspertrollen og applisere metoder som øker pasientens selvstendighet og autonomi. Det er en utbredt oppfatning blant fysioterapeuter at det er viktig å gjøre riktige øvelser, underforstått at det er farlig om pasienten gjør feil. Det er videre trolig en oppfatning om at færre konsultasjoner for hver pasient, gir tap av inntekt.

Fra det offentliges side, er det viktig at retningen som stakes opp, etterfølges med finansieringsmodeller som gir gode insentiver. I dag er det for eksempel ingen fysioterapitakst for oppfølging av pasienten over telefon; dette medfører unødig bruk av personlig oppmøte hos fysioterapeuten.

Litteratur:

  1. Folkehelseinstituttet: Sykdomsbyrde i Norge 1990-2013. In., vol. 1; 2016.
  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V et al: Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012, 380(9859):2163-2196.
  3. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J: Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002, 48(2):177-187.
  4. Lorig KR, Holman H: Self-management education: history, definition, outcomes, and mechanisms. nn Behav Med 2003, 26(1):1-7.
  5. Newman S, Steed L, Mulligan K: Self-management interventions for chronic illness. Lancet 2004, 364(9444):1523-1537.
  6. Battersby M, Von Korff M, Schaefer J, Davis C, Ludman E, Greene SM, Parkerton M, Wagner EH: Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf 2010, 36(12):561-570.
  7. Helse og omsorgsdepartementet: Fremtidens primærhelsetjeneste – nærhet og helhet. Stortingsmelding Nr. 26. 2014.
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Den viktige pasientsamtalen

I behandling av pasienter med smerte er kvaliteten på pasientsamtalen avgjørende for pasienttilfredsheten og trolig også utfallet. Ofte baserer behandlingen seg på at pasienten får en økt forståelse av- og endret adferd i forhold til plagene i hverdagen. Med andre ord starter behandlingen når pasienten går ut av døren. Kan vi som fysioterapeuter nok om pasientsamtalen som metode, og vet vi nok om hva den inneholder? Svaret er nei. En forutsetning for en kvalitativ god samtale er ha interesse for og kunnskap om pasienthistoriene. Tilfanget av forskning som belyser hvordan pasientene tenker om plagene er økende.

patient interview ii

Et eksempel er doktorgradsarbeidet til Birgitte Ahlsen, der hun har dybdeintervjuet menn med nakkesmerter. Artikkelen Troubled bodies – troubled men: a narrative analysis of men’s stories of chronic muscle pain, beskriver hvordan de mannlige pasientene forklarer nakkesmertene og hvordan deres subjektive erfaringer interagerer med kulturelle normer for maskulinitet. Mennenes forklaringer kan oppsummeres slik:

  • De er offer for omstendighetene (utenfor min kontroll); fysisk skade, gener, arbeidskrav etc.
  • De sliter med å etablere legitimitet (maskulinitet) med bakgrunn i biomedisinske funn
  • De forteller om personlig stress, men uten emosjonell innlevelse
  • Mangel på kontroll, det å miste seg selv er en kontinuerlig undertekst i fortellingene

Ahlesen konkluderer med at mennenes forklaringer viser en skjør balanse mellom å følge etablerte normer for maskulinitet, og behovet for å uttrykke sårbarhet. Hun argumenter for at helsepersonell bør være sensitive overfor disse spørsmålene.

Hva vet vi om hva fysioterapeuter snakker med pasientene om? En belgisk studie av Roussel m.fl. fra 2015 kartla hvordan fysioterapeuter tar opp helsehistorien til ryggpasienter. Forskerne fant at tanker om nåværende situasjon, kontroll over og fysiske årsaker til ryggsmertene; hovedsakelig biomedisinske spørsmål og ikkepsykososiale opplevelser ble tematisert. Utvikling over tid, konsekvenser, kontekst og emosjonelle opplevelser ble i liten grad tematisert.

 

I boken det kliniske intervjuet av Rønnestad og Lippe, oppsummerer professor Arnstein Finset de senere års forskning på hvilke aspekter som har betydning for pasienttilfredshet i relasjonen lege – pasient. Funnene kan oppsummeres i følgende punkter:

  • følelsesmessig engasjement fra behandleren
  • glede over bedring, empatisk respons på pasientens bekymringer
  • oppgaverettet, kompetent, informativ og lyttende kliniker
  • emosjonell kvalitet viktig

patientinterview

Når det gjelder helsehistorien for pasienter med smerte anbefaler Ramberg & Diseth (2012) følgende to spørsmål som utgangspunkt: Hva gjør du når smerten kommer? og har du noen å snakke med om disse plagene dine? Breivik med flere (2008) anbefaler åpne spørsmål om hvordan smertene begrenser i hverdgen, søvn, seksualfunksjon og sosialt liv. Et utgangspunkt kan være spørsmålet hvordan er en vanlig dag for deg?

I pasientsamtalen er det avgjørende å på et tidlig tidspunkt kartlegge hva pasienten ønsker å få ut av behandlingen og forventningene. Disse temaene kan være et godt utgangspunkt for at pasienten kan få mulighet til å fortelle hva som er viktig og hvordan situasjonen oppleves. Basert på egen erfaring tenker jeg ikke at pasienten alltid har semmenterte oppfatninger om dette – heldigvis! Den gode pasientsamtalen kan fungere som en hjelp for pasienten til å reflektere over viktige temaer for plagene. Jeg mener denne dialogen og refleksjonen med fordel kan foregå i situasjoner der pasienten utfører øvelser eller fysisk aktivitet. Det er god fysioterapi! Denne fysioterapeutrollen handler om å slippe kontroll og endre fokus. Er vi som profesjon rede til dette?

 

Her kan du lese mer:

Ahlsen, B., et al. (2012). «Troubled bodies–troubled men: a narrative analysis of men’s stories of chronic muscle pain.» Disability & Rehabilitation 34(21): 1765-1773.

Benedetti, F. (2011). The patient’s brain: The neuroscience behind the doctor-patient relationship New York: Oxford University Press

Brevik H et al. (2008). “Assessment of Pain” 101:17-24

Dwamena, F., et al. (2012). «Interventions for providers to promote a patient-centred approach in clinical consultations.» Cochrane Database of Systematic Reviews 12: Cd003267.

Ramberg & Diseth (2012). “Barn med langvarig smerte:Fanget I vonde sirkler-veier ut”.  Tidskrift for Norsk Psykologforening 49:241-6

Roussel, N. A., et al. (2016). «History taking by physiotherapists with low back pain patients: are illness perceptions addressed properly?» Disability & Rehabilitation 38(13): 1268-1279.

Rønnestad, M. H. and A. L. v. d. Lippe (2002). Det kliniske intervjuet. Oslo, Gyldendal akademisk

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Den brysomme smerten

For de aller fleste som oppsøker behandling or muskelskjelettsykdom er smerte i aktivitet eller hvile hovedproblemet. Hvordan helseprofesjonsutøvere møter pasientens smerteopplevelse kan være avgjørende for et vellykket utfall av behandlingen. Få fysioterapeuter, og trolig også andre helseprofesjonsutøvere, har oppdatert kunnskap om langvarig smerte og fysisk aktivitet. Den rådende forståelsen i mange tiår var at smertene i muskelskjelettsykdom, skyldtes betennelse. Av dette fulgte anbefalinger om avlastning og hvile. Nyere forskning har forlatt denne modellen, og det er i dag konsensus, i alle fall på overflaten, blant helseprofesjonsutøvere at pasienter med langvarig smerte bør anbefales å opprettholde aktivitet. Dette generelle rådet kan høres tilforlatelig ut, men hva betyr egentlig å opprettholde daglige aktiviteter? Behandligstiltak for pasienter med langvarig smerte må være individualisert og plassert inn i en kunnskapsbasert forståelsesramme.

 

Det har i de siste årene vært et økende oppmerksomhet mot behandlingsopplegg for langvarig smerte. Innholdet i mange av disse tilnærmingene er at langvarig muskelskjelettsmerte ikke er et tegn på vevsødeleggelse, og dermed ikke er farlig. Denne forståelsen kan sees på som en smertebehandling versjon1.0; det vil si en motreaksjon mot det tradisjonelt rådende synet om smerte som betennelse. Det er imidlertid mangelfullt om behandlingen begrenser seg til kun en generell pasientopplæring om smertefysiologi. I tillegg kan utsagn som «smerten sitter kun i hodet ditt», tolkes som at den kun er noe pasienten innbiller seg.

9311-explain-pain-audio-book

 

The International Association for the Study of Pain (IASP) definerer langvarig smerte som en ubehagelig sensorisk og følelsesmessig opplevelse forbundet med vevsskade eller truende vevsskade, eller beskrevet med ord som for en slik skade. De emosjonelle opplevelsene kan være relatert til katastrofetenkning, f.eks. dette har jeg ikke kontroll på, jeg blir aldri bra, redsel, f.eks. det kan ikke være riktig å gjøre dette fordi det kommer til å gjøre vondt, og nedstemthet, f.eks. hva har jeg gjort for å fortjene dette? Alt dette er aspekter av hverdagslige opllevelser, som vi kan kjenne oss igjen i. Problemet er at for mange av pasientene med langvarige plager, tar disse emosjonene stor plass. I tillegg, opplever mange pasienter at smertene tapper dem for energi, slik at de har mindre overskudd i hverdagen.

 

Smerteforskning rettet mot mukelskjelettsykdommer har det siste tiåret gjort betydelige fremskritt. Øvelser og fysisk aktivitet er den mest nyttige behandlingsformen for langvarige smerter ved muskelskjelettykdom. Hvordan kan så denne nye kunnskapen integreres i behandlingen? To viktige stikkord er smertemonitorering og gradvis eksponering. Dette bør betraktes som versj.2.0 i behandling av smerte.

 

Smertemonitorering vil si at man følger opp pasienten i forhold til smerteintensitet under utførelse av aktiviteter. Det er da i mange tilfeller hensiktmessig å innføre en nummerisk smerteskala for pasienten, der 0 er ingen smerte og 10 er værst tenkelige smerte. Oppgaven til pasienten er å registrere smerte under og etter hverdagslige aktiviteter og fysisk aktivitet. Undertegnede informerer oftest pasientene om at smerteintensitet opptil 3 (mild smerte), under eller etter aktiviteter, ikke er farlig. Pasienten oppfordres til å velge bevegelsesstrategier som minimaliserer smertene, det kan være å redusere eksponeringstiden, kraften, eller justere bevegelsesbanen. Jeg mener at det her er viktig å individualisere, slik at pasienten får konkrete råd tilpasset sin situasjon. Videre er det viktig at begrunnelsene for å unngå høyere smerte i aktiviteter, diskuteres med pasienten. Det er en økende dokumentasjon på at kraftig eksponering av smerte akselrerer nevrofysiologiske sensitiseringsprosesser i de perifere nervene og sentralnervesystemet. Nevrofysiologiske signalveier er svært trenbare, noe som ikke er en hensiktmessig effekt for nosicepsjon. Aktivitet som ikke er smertefull, eller inneholder et minimum av smerte, kan omtales som desensitiserende trening. Smertemonitorering har vært mye brukt i behandling av seneplager i hæl og kne. Det er ikke forskningsmessig belegg for å sette en grense på 3 på den nummeriske smerteskalaen, andre har anbefalt 5. Denne smertemonitoreringstankegangen er mindre utbredt i behandling av rygg- og skuldersmerte. Enkelte erfarne klinikere har hevdet at pasienter med skuldersmerte ikke bør anbefales smertefulle aktiviteter i det hele tatt. Det er imidlertid problematisk å begrunne at smerteprosesser i skulderen er prinsipielt anerledes enn i bena.

 

Gradvis eksponering er en samlebetegnelse for behandling som utsetter pasienten for øvelser som aktiverer emosjonelle smerteopplevelser. Denne prosessen krever omfattende kunnskap fra behandleren om smertemekanismer, frykt for bevegelse og sensitiseringsmekanismer. I tillegg til dette setter behandlingen krav til en «sokratisk» dialog, der pasienten får mulighet til å erfare. Tilslutt er kunnskap om  prinsippene for aksept og forpliktelsesterapi (ACT) og øvelsesbehandling nødvendige forutsetninger. Den stegvise prosessen for gradvis eksponering innebærer å utdanne pasienten om smerte, identifisere «truende» bevegelsesoppgaver, sette spesifikke, målbare, oppnåelige, realistiske og tidsavgrensede mål og adressere pasientens emosjonelle opplevelser under og etter utførelsen av de truende bevegelsesoppgavene. Det er viktig med en balanse i behandlingen som sørger for endring av smertehukommelsen knyttet til truende oppgaver, uten at eksponeringen er så kraftig at den underbygger videre sensitisering.

 

ilustraciones-sunyata-explain-pain

Modeller for gradvis eksponering og smertemonitorering kan utføres parallelt og ivareta ulike deler av behandlingen. Gradvis eksponering kan for enkelte pasienter være et nødvendig premiss for å komme i gang med aktivitet. Smertemonitorering kan gi pasienten økt selvmestring i forhold til hjemmeøvelser og funksjonelle fysiske aktiviteter. Jeg er selv tilhenger av å holde kommunikasjonen med pasienten på et praktisk nivå, der pasienten selvmestring er sentralt. Selv tar jeg ofte med pasienten ut av behandlingsrommet og inn i en annen kontekst, i denne delen av behandlingen.

 

Min erfaring er at de fleste klinikere vil være enige om de nevnte behandlingsmodellene. Utfordringen er at bevisstheten trolig er langt lavere om hva som er trusler mot denne tankegangen. For det første har begrepet veiledet trening slått rot hos fysioterapeuter. Dette kan forstås som en ekspertkompetanse, der fysioterapeuten korrigerer skadelige bevegelser pasienten utfører. Denne typen praksis er vanlig, på tross av at det er lite belegg for å definere noen bevegelser som riktigere enn andre. I tillegg fører denne praksisen lett til at pasienten opplever mindre selvmestring og i mindre grad tør å utfordre seg selv. For det andre begrunnes øvelsesbehandling ofte med behovet for økt styrke, ikke redusert smerte. Dette behøver ikke stå i motsetning til hverandre, men kan skape uklarheter i kommunikasjonen med pasienten. For det tredje fører dagens inansieringsordning for fysioterapi ikke til at terapeuten stimuleres til å holde antall individuelle konsultasjoner lavt. I tillegg utløser ikke oppfølging av pasientens fysiske aktivitet, tilsvarende takster. Det er en klar motsetning mellom antallet individuelle konsultasjoner og pasientens selvmestring.

 

daglige aktiviteter

Øvelsesbehandling av pasienter med langvarig smerte, slik som ved muskelskjelettsykdom, krever som tidligere nevnt avansert kompetanse av behandleren. Det arrangeres allerede gode kurs om dette på masternivå, foreksempel på Masterstudiet i fysioterapi, ved Høgskolen i Oslo og Akershus (MAFYS4100). I dag mangler de fleste av helseprofesjonsutøverne i primærhelsetjenesten denne kompetansen. Utfordringene i dette praksisfeltet er godt dokumentert i Stortingsmelding Nr. 26 og den nylig publiserte rapporten om sykdomsbyrde fra Folkehelseinstituttet.

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Konseptualisering og måling av funksjon i skulderspesifikke spørreksjemaer

I rehabilitering av pasienter med muskelskjelettsykdommer er pasientrapportert utførelse av hverdagslige aktiviteter det viktigstre utfallsmålet etter behandling. På grunn av dette, ble en rekke spørreskjemaer utviklet fra midten av 90-tallet for å måle utfallet av skulderbehandling. En rekke av disse har blitt oversatt til norsk, og er i bruk i både kliniske som forskningmessige settinger. I tillegg, er det innenfor skulderrehabilitering brukt måleinstrumenter som er en kombinasjon av tester og spørreskjema, såkalte komposittskårer. Resultatene fra alle disse målemetodene rapporteres i form av en relativ sumskår (ofte 0 – 100, best – værst) . Den store variasjonen i innhold for disse målemetodene kan føre til at nytteverdien av behandlingen feilrapporteres for denne pasientgruppen.

I en nylig publisert studie i tidsskriftet Journal of Rehabilitation Medicine har Sigrid Østensjø sammen med undertegnede undersøkt hvordan funksjon er konseptualisert og målt i spørreskjemaene. Studien er en videreføring av en tidligere studie, der vi lenket innholdet til skulderspesifikke målemetoder til Verdens helseorganisasjons internasjonale klassifikasjon av funksjon, funksjonshemming og helse (ICF). Emneområdene fra ICF dekker kroppsfunksjon og –struktur, aktiviteter og deltagelse. Selv om det ved laseringen ikke ble formalisert et skille mellom aktiviteter og deltagelse, har det blitt foreslått at kapitlene d1-d6 (untatt ICF kategorien assistere andre), representerer aktiviteter, mens kapitlene d7-d9 representerer deltagelse (se tabell under).

 

ICF kap

 

Disse tre nivåene blir ofte benevnt som kroppslig, personlig og sosialt nivå. For emneområdene aktiviteter og deltagelse, skiller ICF mellom kapasitet (eng. capacity), som er utførelse i et standardisert miljø, og utførelse (eng. performance) som er utførelse i pasientens virkelige miljø. I tillegg har evne til (eng. capability), som er evne til å utføre i et relevant miljø, blitt foreslått som en tredje kategori. Kapasitet, utførelse og evne til representerer trolig distinkte konstrukter som man bør ha et bevisst forhold til når man utformer spøsmål til pasientene. Det gjør trolig vesentlig forskjell om du spør en pasient om han har evne til å utføre en fritidsaktivitet, eller om han faktisk har utført den.

På bakgrunn av den tilsynelatende store variasjonen mellom de skulderspesifikke spørreksjemaene bestemte vi oss derfor for å først analysere hvordan enkeltspørsmålene i målemetodene var fordelt med tanke på de kroppslige, personlige og sosiale nivåene. Deretter undersøkte vi hvordan funksjon i henhold til de tre nivåene var målt i skjemaene.

I alt ble 17 skulderspesifikke målemetoder analysert, deriblant de kjente Disabilities of the Arm, Shoulder and Hand (DASH), Shoulder Pain and Disability Index (SPADI) og Oxford Shoulder Score (OSS). Analysene våre viste at målemetodene var svært forskjellige med tanke på hvilke nivåer av funksjon de dekker. I figuren under kan du se hvordan dette kan illustreres i forhold til kroppslig-, personlig og sosialt nivå:

 

ICF nivåer i skjemaene

 

Figuren over viser hvordan 7 av spørreskjemaene dekket alle de tre nivåene, 8 dekket to nivåer og de 2 siste kun ett enkelt nivå. Vi fant med andre ord store variasjoner i båndbredden til spørreskjemaene.

I de videre analysene fant vi at kapasitet (capacity), evne til å utføre (capability) eller utførelse (performance) var ujevnt fordelt mellom målemetodene, og i mangetilfeller inkonsistent brukt i samme målemetode. Figuren under illustrerer hvordan dette så ut for de målemetodene som inneholdt spørsmål på personlig nivå (ICF emneområdet aktiviteter):

 

capability performance ICF activities

 

Analysene viser at enkelte målemetoder, foreksempel DASH, tester evne til å utføre aktiviteter, mens andre, foreksempel SPADI måler faktisk utførelse. Enkelte andre målemetoder, foreksempel OSS, inneholder en miks av de foregående.

Resultatene fra denne studien bør benyttes av forskere og klinikere for å velge en målemetode som er best egnet for behovene de har. Vi håper videre at artikkelen vgil fremme en debatt om hva og hvordan når det gjelder målinger av funksjon hos pasienter med muskelskjelettlidelser. Vi vil hevde at skulderrehabiliteringsfeltet har vært preget av liten interesse for grunnleggende diskusjoner knyttet til hva og hvordan funksjon skal måles. Nye retningslinjer for vurdering av måleegenskaper til pasientrapporterte målemetoder (de såkalte COSMIN-retningslinjene) er viktig, men må suppleres med grunnleggende diskusjoner om hvilke konstrukter klinikerne påvirker hos pasientene. Dette er en debatt som er knyttet til virkningsmekanismene for behandlingen – der er foreløpig mye ukjent når det gjelder øvelsesbehandling. Et eksempel på en slik debatt, er om utfalles av behandling skal måles med tanke på om pasienten har forbedret evne til å utføre hverdagslige aktiviteter, eller om han/hun faktisk utfører disse aktivitetene. Det kan argumenteres begge veier, men forfatteren av denne bloggen vil argumentere for at konstruktet evne til å utføre (capability), best fanger det som øvelsesbehandling for fysioterapeuter retter seg mot. Om pasienten utnytter dette mulighetsrommet til å utføre aktivitetene kan handle om faktorer som enten tar lengre tid, eller faller utenfor rammene av skulderrehabilitering i primærhelsetjenesten. Konsekvensen av å velge en målemetode som fanger konstruktet utførelse, kan da bli at behandlingseffekter underrapporteres. På et mer overordnet nivå kan den manglende bevisstheten om utfallsmålinger i skulderrehabilitering føre til at beslutningstakeres grunnlag for bevilgninger til behandling og forskning, er for dårlig. Det er samfunnet ikke tjent med!

Her kan du lese hele artikkelen.

 

 

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Sykdomsbyrde i Norge 1990 – 2013

Folkehelseinstituttet presenterte sist onsdag en rapport som sammenligner byrden og utviklingen av ulike typer sykdommer og lidelser i Norge. Rapporten er et resultat av de såkalte GBD-prosjektet some er et samarbeid mellom mer enn 1100 forskere i 110 land. I GBD-prosjektet og dermed denne rapporten  benyttes fire mål for sykdomsbyrde: antall dødsfall, tapte leveår, helsetap og helsetapsjusterte leveår (Eng. Disability-Adjusted Life Year – DALY). DALY er et samlemål på tap av leveår ved dødsfall og helsetap. Dette muliggjør sammenligninger mellom tilstander som medfører død og som i større grad er preget av helsetap, foreksempel muskelskjlettlidelser. Det er første gang slike tall blir presentert i Norge og rapporten fikk betydelige mediaoppslag.

sykdomsbyrde

Resultatene fra rapporten viser at de viktigste årsakene til død er sykdommer som i stor grad rammer eldre, spesielt hjerte- og karsykdommer og kreft . Blant viktige årsaker til tapte leveår, som ofte rammer i yngre alder, er selvmord, overdoser, brystkreft, lungekreft og veitraffikkskader. Muskel- og skjelettsykdommer, samt psykiske lidelser og ruslidelser er de viktigste årsakene til helsetap i Norge. Psykiske lidelser bidrar til helsetap i alle aldersgrupper, mens helsetapet knyttet til muskel- og skjelettsykdommer øker med alder.

 

 

Tallene viser at muskel- og skjelettsykdommer er en av de hyppigste årsakene til at folk oppsøker helsetjenester, og blant de hyppigste årsakene til sykefravær, rehabilitering og uførepensjonering. Samlet står disse muskel- og skjelettsykdommene for 13.4% av det totale antallet DALY i Norge i 2013, og er dermed den største sykdomsgruppen. Selv om muskel- og skjelettsykdommer kan bidra til død, bidrar de i hovedsak til sykdomsbyrde gjennom helsetap. Den høye prevalensen av disse lidelsene i befolkningen er trolig en viktig årsak til de høye tallene for muskel- og skjelettsykdommer. Det ble rapportert en økning i sykdomsbyrde fra muskel- og skjelettsykdommer i perioden 1990 – 2013, og det forventes en videre økning fremover. Økningen var klart størst for gruppen korsrygg- og nakkesmerter. Disse tallene støttes av tilsvarende funn i befolkningsundersøkelsen HUNT, fra Nord-Trøndelag. Rapporten skriver videre “om man ikke finner nye effective strategier for forebygging og behandling, er det grunn til å forvente at muskel- og skjelettsykdommer vil fortsette å være en svært viktig del av den norske sykdomsbyrden i fremtiden”. Klar tale med andre ord!

 

GBD-prosjektet har valgt å definere seks grupper muskel- og skjelettsykdommer, nemlig revmatoid artritt, artrose, nakkesmerter, korsryggsmerter, urinsyregikt og “andre” muskel- og skjelettsykdommer (en bred samling av mange forskjellige sykdommer).  Når det gjelder de ulike muskel- og skjelettsykdommene, bidrar korsrygg- og nakkesmerter til klart flest DALY. I rapporten drøftes det mangler i datagrunnlaget for muskel- og skjelettsykdommer, der manglende datagrunnlag for aldersgruppen 0 – 4 år og at systematisk innsamling av data for prevalens mangler i Norge, trekkes frem. Det som ikke blir drøftet i rapporten, er mulige feilkilder som en følge av kategoriseringen av muskel- og skjelettsykdommer. Det store spørsmålet er hvor det er blitt av skuldersmerte? Sannsynligvis er tallene bakt inn i kategorien nakkesmerter. Dette vil ikke påvirke den samlede DALY for gruppen, men kan gi et skjevt bilde av typen plager. Det er  i så fall uheldig at denne kategorien har fått navnet nakkesmerter. Dette tolkes lett som smertetilstander som har sitt utspring i columna og tilhørende strukturer. Basert på egen klinisk erfaring, kliniske og epidemiologiske studier, medfører ikke dette riktighet. Den store gruppen pasienter med smerte i dette kroppsområdet, har smerter relatert til skapula, skulderleddet og armene. Hos mange pasienter er de subakromiale smrtene fremtredende, hos andre mer myalgi knyttet til skapulamusklene (nakken). Undertegnede har selv publisert forskning som viser at minst 2 av tre pasienter med smerte i skulderleddet også har myalgismerter i nakkeregionen. Begrepsbruken er viktig og kan få konskvenser for tildelinger til forskningsprosjekter og ha kliniske implikasjoner. En årsak til den uheldige kategoriseringen som er valgt i GBD-prosjektet, er trolig det komplette kaos som råder i det medisinske diagnostike klassifiseringssystemet (ICD) for skuldersmerte, med overlappende og mangelfulle kategorier. Det er bare å håpe på en opprydning i neste revisjon av klassifiseringssystemet, som trolig kommer i 2017. Det er tydelig at navnet på denne kategorien er umusikalsk for flere, da det lanseringsdagen for rapporten flere ganger ble referert til skuldernakkesmerter.

 

Rapporten fra Folkehelseinstituttet kommer til å være et viktig dokument i undervisning og orskning knyttet til muskel- og skjelettsykdommer. Det vil trolig bli lettere for beslutningstakere (politikere) å prioritere opp sykdommer som gir stort helsetap fremfor død. Det er ellers å håpe at svakhetene knyttet til kategoriseringen av muskel- og skjelettsykdommene ikke gir et økt fokus på rehabilitering av nakkepasienter. Skrekkbildet vil være en økende bruk av treningsmaskiner som måler og trener nakkerotasjon, blant klinikere. Istedet trenger disse pasientene fysisk aktivitetstilnærming for overkroppen, som er av høyere kvalitet enn det som tilbys av fysioterapeuter i dag!

 

Rapporten til Folkehelseinstituttet kanlastes ned fra Folkehelseinstituttets nettside

 

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Domener som fanges av standardiserte målemetoder for skuldersmerte; mot en samordning av utfallsmål?

I en nylig publisert oversiktsartikkel har en gruppe ledende forskere fra Australia, Canada og UK undersøkt innholdet i standardiserte målemetoder som er brukt i RCTer som undersøkte effekten av fysioterapi på pasienter med skuldersmerte [1]. Bakgrunnen for studien er en erkjennelse av at det er behov for et opprydningsarbeid innenfor skulderrehabiliteringsfeltet, der man oppnår en større grad av likhet i hvilke utfallsdomener som evalueres. Forskjellige grupper av skuldersmerte var representert,  slik som subakromiale smerter, kapsulitt og ikkespesifikk skuldersmerte. Tilsammen 171 studier frem til mars 2015 ble inkludert etter søk i CENTRAL, MEDLINE, EMBASE og CINAHL Plus. Hovedresultatene viser at smerte ble hyppigst målt (87%) i studiene, fulgt av funksjon (72%) og bevegelsesutslag (67%). Bivirkninger, pasienttilfredshet, styrke og helserelatert livskvalitet ble målt i 18-27% av studiene. Arbeidshelse og henvisning til kirurgi ble målt i mindre enn 5% av studiene. Forskerne fant en kraftig økende bruk av domenet funksjon i perioden 1973-2014. Forfatterne konkluderte med at det er en stor variasjon i forhold til hvilke domener som måles, og at resultatene fra denne litteraturstudien er et utgangspunkt for å utvikle et kjernesett av utfallsmål for fremtidige studier.

Styrker ved studienskuldermål bilde

Denne litteraturstudien er viktig, men har noen klare svakheter jeg kommer tilbake til. Utgangspunktet for dette initiativet for å utvikle et felles sett med domener er som tidligere nevnt at dette er et stort behov innenfor flere områder av muskelskjelettrehabilitering. Allerede er det gjennomført et tilsvarende arbeid innenfor ryggrehabilitering og osteoartritt. Som vanlig ligger skulderrehabiliteringsfeltet langt etter. Litteraturstudien anvender det såkalte Outcome Measures in Rheumatology (Omeract 2) rammeverket sin terminologi [2] og viser til at det er satt ned en OMERACT-arbeidsgruppe som skal jobbe videre med dette spørsmålet. Dette er et svært viktig initiativ, og det er gledelig at det ser ut til å være en økende samordning på tvers av muskelskjelettlidelser. En annen styrlke med denne oversiktsartikkelen, er at den bruker de samme domenekategoriene som ble brukt i en tidligere Cochrane-review fra en av medforfatterne. Denne Cochrane-reviewen er for tiden under oppdatering.

Svakheter ved studien

For å rettferdiggjøre studien, hevder forfatterne at domenene i utfallsmål for skuldersmerte ikke tidligere er undersøkt. Dette er bare delvis sant. Undertegnede og medforfattere publiserte i 2013 en artikkel med tittelen “A systematic review of measures of shoulder pain and functioning using the International classification of functioning, disability and health (ICF)” [3]. I denne artikkelen analyserte vi innholdet av målemetodene I alle typer studier, ikke bare RCTer. I motsetning til Page og medforfattere, analyserte vi innholdet i spørreskjemaene på item-nivå, og lenket alle konseptene til ICF-rammeverket. Dette er et sentralt poeng, da de fleste av de pasientrapporterte spørreskjemaene ikke kun dekker hverdagslige aktiviteter, men også smerte og i mange tilfeller søvn og psykologiske faktorer. I artikkelen til Page og medforfattere blir ikke funksjonsbegrepet nærmere definert, og det er ingen referanser til ICF. Det er uklart for leseren om det funksjonsbegrepet forfatterne har brukt, inkluderer psykologiske faktorer og sosial fungering. På tross av at formålet med vår studie var bredere, er resultatene på flere områder ganske like.

Diskusjonsdelen av artikkelen er skjemmet av enkelte lite underbygde påstander, slik som at domenene bevegelsesutslag og styrke trolig ikke er aktuelle kjernedomener for rotator cufflidelser (subakromiale smerter). Dette kan tyde på at forfatterne ikke har god nok kjennskap til de kliniske feltet. Skulderrehabilitering er i økende grad vært influert av øvelsesbehandling, der formålet er å redusere smerte og bedre rotator cuff senenes lasteevne. Mange av øvelsesoppleggene er inspirert av kunnskap som er hentet frem fra tilsvarende øvelsesbehandling på senevev andre steder i kroppen. Denne trenden innenfor rehabilitering vil trolig forsterkes, noe som tilsier en økende fokus på å måle styrke og bevegelsesutslag. Det er også slik at en rivende utvikling innenfor sensorteknologi, gjør at disse domenene snart kan fanges opp med målemetoder som er både rimelige og nøyaktige.

En siste svakhet ved artikkelen, er at den har undersøkt artikler helt tilbake til 70-tallet. Dette avstedkommer det selvfølgelige resultatet at eldre artikler i større grad fokuserer på bevegelsesutslag og styrke. I diskusjonsdelen medgir forfatterne at skulderspesifikke spørreskjemaer først var tilgjengelig fra midten av 90-tallet (og senere for andre språkoversettelser). Oversiktsartikkelen ville hevet seg ved å avgrense til foreksempel siste 10 år.

Betydningen av resultatene

Betydningen av denne oversiktartikkelen og det arbeidet som er igangsatt for å utvikle et kjernesett av domener for fremtidige studier, bør ikke undervurderes. Det er utvilsomt et stort behov, ikke bare for å bli enige om felles målemetoder, men også å utvikle øvelsesbehandlinger av høyere kvalitet. Trolig haster det siste mest! En bekymringen er imidlertid at gruppen bak initiativet ikke godt nok kjenner til og representerer det kliniske feltet. Det lover heller ikke godt at forskningsgruppen ikke referer til forskning som allerede er publisert.

Synes du dette var interessant, kan du lese mer:

  1. Page, M.J., et al., Core domain and outcome measurement sets for shoulder pain trials are needed: systematic review of physical therapy trials. Journal of Clinical Epidemiology, 2015. 68(11): p. 1270-81.
  2. Boers, M., et al., Developing core outcome measurement sets for clinical trials: OMERACT filter 2.0. J Clin Epidemiol, 2014. 67(7): p. 745-53.
  3. Roe, Y., et al., A systematic review of measures of shoulder pain and functioning using the International Classification of Functioning, Disability and Health (ICF). BMC Musculoskeletal Disorders, 2013. 14: p. 73.
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