Marshall A, Joyce CT, Tseng B, et al. Changes in Pain Self-Efficacy, Coping Skills and Fear Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain. Pain Med. 2021 Oct 26. pii: 6410653. doi: 10.1093/pm/pnab318. (Original study)

OBJECTIVE: We evaluated exercise interventions for cognitive appraisal of chronic low-back pain (cLBP) in an underserved population.

METHODS: We conducted a secondary analysis of the Back to Health Trial, showing yoga to be non-inferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed using the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ) and Fear Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references.

RESULTS: Participants (mean age = 46) were mostly female (64%), black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD]=7.0, 95%CI: 4.9, 9.0; PT, MD = 6.9, 95%CI: 4.7, 9.1; and education, MD = 3.4, 95%CI: 0.54, 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest among yoga and PT groups (MD=-3.0, 95%CI: -4.4, -1.6; MD=-2.7, 95%CI: -4.2, -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks.

CONCLUSION: All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income racially-diverse adults with cLBP.

TRIAL REGISTRATION: Identifier NCT01343927.

Discipline Area Score
Rehab Clinician (OT/PT) 5 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

This is interesting.

Rehab Clinician (OT/PT) rater

One of the few studies that I am aware of, as a physical therapist, that examined the effect of different treatments on self-efficacy, catastrophizing, and fear avoidance among low-income, racially diverse adults with cLBP. With that said, it would have been clinically beneficial to classify all patients at intake by psychosocial risk level e.g., using STarT tool and randomizing those at medium and high risk. Patient at low risk will most likely benefit regardless of treatment rendered. Without knowing the patient's risk, it is difficult to recommend one treatment over another based on the study's results.

Rehab Clinician (OT/PT) rater

The finding that there were no differences between groups but all 3 groups improved does not indicate that all interventions were effective. This is basic statistics and it is surprising that the reviewers allowed this through.
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