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Cognitive representations in low back pain in patients receiving chiropractic versus physiotherapy treatment

Clinical Research 7 min 192

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Created On: 11/02/2020

Cognitive representations in low back pain in patients receiving chiropractic versus physiotherapy treatment

Low back pain is the leading cause of disability and functional limitations in day-to-day activities.

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Key take away

Cognitive-behavioural therapy is well known treatment for patients with chronic or sub-acute low back pain and may be effective in targeting and promoting illness beliefs. This study is designed to provide information on various cognitive variables influence functional concept of disability. Chiropractic treatment have been shown more effective in managing back pain than physiotherapy treatment

Background

Low back pain is the leading cause of disability and functional limitations in day-to-day activities. Its symotoms are pain, restricted amplitude of movements, diminished muscle strength, muscular spasms and postural changes. This is a second to the common cold as a cause of absent from work. Its prevalence found to be more in many countries such as UK: 59%, Switzerland: 20–28.5%, Greece: 31.7%, Spain: 50.9% and less in Portugal: 49%. However, this research anticipates that about 80% of world population will experience episode of LBP and about 30% with chronic symptoms. Furthermore, depending on its chronicity, different types of treatments for LBP are available, for instance, self-care measures, bed rest or medication, to exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioural therapy (CBT) or progressive relaxation. Out of them physiotherapy (PT) is widely used treatment for both acute and chronic LBP, but it is partially reimbursed. So, we aimed to analyzed the differences between Physiotherapy treatment (PT) and Chiropractic treatment (CT) in LBP patients in order to find out which is more effective.

Rationale behind research

Very few studies were conducted which emphasized on variables such as satisfaction with care, illness perceptions, beliefs about pain and medicines, attitudes towards doctors and medicine, suffering, adherence and functional incapacity in LBP patients. Therefore, with chiropractic treatment chances of recovery are more than physiotherapy treatment and may be considered as an alternative to many pharmacological treatments in preventing illness and promoting health.
To study the mental representations of low back pain patients who receiving chiropractic versus physiotherapy treatment

Objective

To find the predictors of functional incapacity in the Chiropractic therapy (CT) and physiotherapy (PT) patients with low back pain.
To evaluate the differences between Chiropractic therapy (CT) and physiotherapy (PT) with regards to cognitive perceptions in LBP patients.

Method

Study outcomes

To access various variables such as satisfaction with care, illness perceptions, beliefs about pain and medicines, attitudes towards doctors and medicine, suffering, adherence and functional incapacity.

Result

Outcomes

Clinical and Sociodemographic Questionnaire: 32 questionnaires assessed on the basis of demographic variables which covers age, gender, education and clinical variables included frequency and intensity of pain, number of medical appointments, duration of treatment, current health status.

Patient Healthcare Questionnaire: Patient satisfaction with health care judged according to six dimensions: access, financial costs, technical quality, communication/information, interpersonal relationships and team coordination. Higher results indicate more satisfaction with the care received. Alphas in the original version ranged from .69 to .87. In this study, internal consistency of the subscales ranged from α = .84 to α = .93.

Illness Perception Questionnaire–Revised (IPQ-R): This questionnaire measures cognitive representations of patients with chronic illness, according to 45 items, divided into nine dimensions: identity, timeline (acute/chronic), consequences, personal control, treatment control, coherence, timeline (cyclical), emotional representations and causes. Alphas in the original version ranged from .75 to .89. In this sample, Cronbach’s alpha values between α = .74 and α = .88.

Beliefs about Pain Control Questionnaire: This evaluates the type and strength of beliefs about pain control, according to 13 items and three subscales: Internal or Personal Control (beliefs about the internal control of pain management), Powerful Others (influence of doctors on pain control) and Chance Events (beliefs about the influence of chance or luck on pain control). In this study, the Cronbach’s alpha values were .69 for Internal Control, .66 for Powerful Others and .80 for Chance Events.

Illness Subjective Suffering Inventory: This questionnaire measures patient's experience of suffering as a psychological state of discomfort and excess of negative emotions (distress). Alphas in the original version ranged from .69 to .85, and .86. to .94. Cronbach’s alpha ranged noticed in this study.

Attitudes towards Doctors and Medicine Scale: The scale determined attitudes towards doctors and medicine, particularly their capability to promote health. In this study, the Cronbach’s alpha values were .74 for the scale Positive Attitudes towards Doctors and Medicine and .70 for the scale Negative Attitudes towards Doctors and Medicine.

Beliefs about Medicines Questionnaire: This questionnaire was designed to measure cognitive representations about medicines. Alphas in the original version was .88 for general overuse and .66 for general harm. In this sample, Cronbach’s alpha values of both subscales i.e. Α = .77.

Reported Adherence to Medication Scale (RAM): The four-item questionnaire was conducted to measure patient's adherence levels of medication, including the frequency of changes on prescribed dosages. Higher scores indicate higher adherence. In the original validation studies, Cronbach’s alpha ranged from .60 to .83. Cronbach’s alpha for the subscale Changes in Dosages was .75 and for the subscale Forgetfulness in Taking Medication was .56.

Oswestry Low Back Pain Disability Questionnaire: The instrument assesses functional incapacity, in LBP patients. Higher scores indicate more disability. Internal consistency values of the original version ranged from .71 to .87. The Cronbach’s alpha, in this sample, was .86.

Conclusion

Result demonstrates the differences in cognitive representations in both groups, showed that CT group had more positive illness representations of personal control, treatment control and coherence; more beliefs regarding internal control and medications overuse by health professionals and less positive and negative attitudes towards doctors and medicine. In contrast to PT group, which exhibited negative representations about identity, timeline (acute/chronic and cyclic), consequences and emotional representation, and more beliefs about powerful others and chance events. Thus, such multidisciplinary approaches of chiropractic treatment are found to be more effective than physical therapy alone in alleviating pain and disability in low back pain sufferers and are associated with better treatment outcomes and less pain intensity.

Limitations

The most important shortcoming is that it is not randomized controlled study
The study used only self-report measures
Recruitment of chiropractic patients from private clinics and were approached by letter, decsribed the study designs, aims and inclusion criteria as well
Partially reimbursement in Portugal for a medical treatments such as physiotherapy, so economic considerations exert influence on healthcare provider's choice
Unable to understand the ideas behind the patient’s choice of type of treatment

Clinical take-away

This study imparts a valuable information about cognitive representations in LBP patients. But, this study does not provide a valid reason for selecting either PT or CT treatment. Thus, further research is warranted for decision-making processes and illness representations and to track the changes in patients, follow-up is required before and after the treatment for the assessment of patient's opinions.