Appendix A
IP 1 How much does your illness effect your life?
IP 2 How long do you think your illness will continue?
IP 3 How much control do you feel you have over your illness?
IP 4 How much do you think your treatment can help your illness?
Q1 = 1st quartile, Q4 = 4th Quartile, PI = Pain Intensity last 24 h, PSFS = Patient Specific Functioning Scale, 4DSQ = Four-Dimensional Symptom Questionnaire.
IP 5 How much do you experience symptoms from your illness?
IP 6 How concerned are you about your illness?
IP 7 How well do you feel you understand your illness?
IP 8 How much does your illness affect you emotionally? (e.g. does it make you angry. Scared. upset or depressed?
Q1 = 1st quartile, Q4 = 4th Quartile, PI = Pain Intensity last 24 h, PSFS = Patient Specific Functioning Scale, 4DSQ = Four-Dimensional Symptom Questionnaire.
Appendix B
The matched-care treament of the Single-Case Experimental Design
Intervention
[The intervention is based on usual care following the low back pain guideline of the Royal Dutch Physiotherapy Association [16] and will target patients whom are classified in ‘patient profile 3’. This means that this study includes patients that have an abnormal course with dominant presence of psychosocial factors impeding recovery.
The intervention is considered to be delivered as proposed in the guideline, with an additional matched-care treatment package. This package focusses on patients’ specific Illness Perception (IPs) regarding his or her low back pain. This means if IPs are considered to be dysfunctional before and during treatment, these IPs will be seen as prognostic factor for poor recovery of pain intensity and physical function. The aim is to alter dysfunctional IPs to more functional perceptions by the advised strategies for consistent (back) pain [5, 8, 15, 17]. These cognitive, exposure and respondent strategies will be response guided at the beginning and during each intervention session.
The additional treatment package will be matched with the scores of the IPs before each treatment session. Patients whose score are within the 4th-quartile range (Table 1), are seen as indicative for dysfunctional IPs, will be challenged to rethink their perception by a combination of the three proposed strategies. This means that the physiotherapist together with the patient must decide on which strategy to start with and when to switch to another strategy. This decision-making process is an essential part of the intervention and will be shaped by shared decision-making [2] and can be seen as a response guided intervention. This treatment approach can be seen more as reflective than as descriptive. Meaning the patient guides her or his own meaningful and safe strategies to cope with their pain condition. The physiotherapist is more a reflective, instead of a problem-solving practitioner. For full description of the treatment package.
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Treatment strategies
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Education [10]
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Exposure [7]
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Graded activity [4, 11]
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Safety behavior [6]
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Underlying paradigm
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Cognitive strategy
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Cognitive strategy
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Operant strategy
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Classical conditioning
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Treatment aim
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Increase level of pain understanding
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Decrease fear related disability
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Increase physical resilience
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Reducing safety behaviour
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Treatment package
Each strategy within the treatment package consists of a diagnostic- and a treatment phase. The diagnostic-phase determines if the strategy is indicated to be used and if so, the treatment phase will then deliver the treatment as intended within this specific strategy.
Pain neuroscience education has been proven to be useful for reducing pain, improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization [9].
The revised neuro physiology pain questionnaire will be used for assessing patients’ baseline knowledge of pain physiology [1]. The outcome of this questionnaire, together with The Brief-IPQ-DLV baseline scores will be determining the content of the treatment phase.
By a number of tools, the patients’ knowledge and perceptions about their pain condition will be discussed. Important part of the intervention will be pain neuroscience education. Main message will be that pain mainly is about being a symptom that is formed from past experiences, sensory input and contextual circumstances [14], not about tissue damage alone.
Is based on the Operant Learning Theory (OLT) introduced by Fordyce for managing chronic pain [3]. The use of OLT has been shown to be useful [4], treatment is advised to be customized to the bio-psych-social needs of the patient [12].
The Phoda will be used to rate the level of patients’ fear related avoidance of daily activities. The outcome of this method, 3–5 most highly feared daily activities, together with The Brief-IPQ-DLV baseline scores will be selected to be expose the feared activities with movement/exercise related OLT.
Exposure with movement will be used to adjust patients’ fear and beliefs about the harmfulness of the daily activity. There will be no upfront defined route of ‘graded exposure’ before the treatment session. The start of the exposure will always be aimed on the least feared activity first but might be directly followed with the most feared activity, depending on the pace in which patients’ fear and beliefs are responding.
Is based on safety behaviour expression, such as propping with hands and avoiding loading painful body part [13].
The diagnostics is primarily done via observation by the physiotherapist during interview, examination and treatment. These observations will focus on safety and communication behaviors and sympathetic responses.
Cited from O’sullivan 2018: “These observations then form the basis of a series of guided behavioral experiments. These guided experiments explicitly seek to reduce sympathetic responses and abolish safety and communicative behaviors (via relaxed diaphragmatic breathing, body relaxation, awareness, and control), prior to and while gradually exposing individuals to their feared, avoided, and painful tasks.”
References appendix B
1. Catley MJ, O’Connell NE, Moseley GL. How Good Is the Neurophysiology of Pain Questionnaire? A Rasch Analysis of Psychometric Properties. The Journal of Pain. 2013;14(8):818–827. doi:https://doi.org/10.1016/j.jpain.2013.02.008.
2. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. Jama: The Journal of the American Medical Association. 2004;291(19):2359–2366. doi:https://doi.org/10.1001/jama.291.19.2359.
3. Fordyce WE. Behavioral factors in pain. Neurosurg Clin N Am. 1991;2(4):749–759.
4. Gatzounis R, Schrooten MGS, Crombez G, Vlaeyen JWS. Operant Learning Theory in Pain and Chronic Pain Rehabilitation. Curr Pain Headache Rep. 2012;16(2):117–126. doi:https://doi.org/10.1007/s11916-012-0247-1.
5. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;(7):CD002014. doi:https://doi.org/10.1002/14651858.CD002014.pub3.
6. Hoffman LJ, Chu BC. When Is Seeking Safety Functional? Taking a Pragmatic Approach to Distinguishing Coping From Safety. Cognitive and Behavioral Practice. 2019;26(1):176–185. doi:https://doi.org/10.1016/j.cbpra.2018.11.002.
7. Hollander den M, Goossens M, de Jong J, et al. Expose or protect? A randomized controlled trial of exposure in vivo vs pain-contingent treatment as usual in patients with complex regional pain syndrome type 1. Pain. 2016;157(10):2318–2329. doi:https://doi.org/10.1097/j.pain.0000000000000651.
8. Jensen M. Toward the development of a motivational model of pain self-management. The Journal of Pain. 2003;4(9):477–492. doi:https://doi.org/10.1016/S1526-5900(03)00779-X.
9. Louw A, Diener I, Butler DS, Puentedura EJ. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation. 2011;92(12):2041–2056. doi:https://doi.org/10.1016/j.apmr.2011.07.198.
10. Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain. 2015;16(9):807–813. doi:https://doi.org/10.1016/j.jpain.2015.05.005.
11. Moseley GL, Vlaeyen JWS. Beyond nociception. Pain. 2015;156(1):35–38. doi:https://doi.org/10.1016/j.pain.0000000000000014.
12. Nielson WR, Weir R. Biopsychosocial approaches to the treatment of chronic pain. The Clinical Journal of Pain. 2001;17(4 Suppl):S114-S127.
13. O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. physical therapy. 2018;98(5):408–423. doi:https://doi.org/10.1093/ptj/pzy022.
14. Ongaro G, Kaptchuk TJ. Symptom perception, placebo effects, and the Bayesian brain. Pain. 2019;160(1):1–4. doi:https://doi.org/10.1097/j.pain.0000000000001367.
15. Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a cognitive-behavioral mediation model. Pain. 1988;35(2):129–140.
16. Staal JB, Hendriks EJM, Heijmans M, et al. KNGF Guideline Low back pain. January 2013:1–7.
17. Vlaeyen JW, Haazen IW, Schuerman JA, Kole-Snijders AM, van Eek H. Behavioural rehabilitation of chronic low back pain: comparison of an operant treatment, an operant-cognitive treatment and an operant-respondent treatment. Br J Clin Psychol. 1995;34 (Pt 1):95–118.
Appendix C
Online questionnaire to assess primary outcomes, Illness Perceptions and co-variates.
All items scored on 11-point scale (0–10) and anchored by words appropriately related to each question. Outcome score were reversed to lower score meaning less dysfunction.
Primary outcome.
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What was the average back pain over the past 24 h?
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In the past week, how difficult was it to perform your self-proclaimed activity?
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How much has the back pain limited you in your daily activities?
Illness Perceptions secondary outcome
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How much does your illness affect your life?
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How long do you think your illness will continue?
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How much control do you feel you have over your illness?
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How much do you think your treatment can help your illness?
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How much do you experience symptoms from your illness?
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How concerned are you about your illness?
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How well do you feel you understand your illness?
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How much does your illness affect you emotionally? (e.g. does it make you angry, scared, upset or depressed?)
Co-variates
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My pain complaints will decrease if I were to exercise.
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When I am in pain, I wonder whether something serious may happen.
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I avoid important activities when I hurt.
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How much have you been bothered by feeling depressed in the last 24-h?
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I can sleep at night.