Discussion
low back pain, acute pain, pain, disability, chronic pain, impaired gait, LBP
DISORDER, CHRONIC LOW BACK PAIN, REGRESSION, CHRONIC PAIN, CENTRAL SENSITIZATION
This study aimed to compare efficacy of CFT and MSI-based treatment on pain, disability, kinesiophobia, and gait kinetics in CNSLBP patients. Evaluation of functional status revealed superiority of CFT approach on reduction in pain intensity, disability, and kinesiophobia through an 8-week intervention and six months follow up over MSI-based treatment.According to the bio-psycho-physiological improvement in recent years, it is time for health-care practitioners to shift their perspective away from a biomedical model, toward prescribing the treatment for CNSLBP based on a multidimensional classification-based approach with the aim of making the treatment more self-centered and focusing on cognitive-behavioral aspects rather than the signs and symptoms associated with the disorder.According to O’Sullivan’s classification, two sensitizations found LBP, including central sensitization affected by psychological and cognitive factors, and peripheral sensitization connected to impairments in movement and controlling movement [Activity avoidance is related to fear, which reflects the belief that activity may result in (re)injury or increased pain as a result of dysfunctional interpretations of pain and injury that can be adaptive in the acute pain stage but contradictorily worsen the problem in the case of chronic pain [To support our results, Vibe Fersum et al. (2013) [After 8 weeks of treatment with both interventions, the evaluation of gait kinetics in people with CNSLBP showed significant improvements in VGRF parameters such as FPF, SPF, MSF, WAR, and POR from baseline. However, the CFT approach appeared to be more effective than the MSI-based treatment. The results showed that, the POR and WAR increased in the self-selected speed in both treatment groups. It means that the time to reach heel-contact and return time from push off have decreased [At the self-selected and fastest walking speeds, WAR and POR increased in the CFT group more than in the MSI group, representing increased speed and decreased time in reaching the FPF peak and returning from the SPF peak. FPF and SPF both increased at the fastest walking speeds in both intervention groups. Generally, more improvement in MSF was observed in the CFT group. To the best of our knowledge, this is the first trial assessing the effects of CFT and MSI-based treatment on gait kinetics in patients with CNSLBP. Our results clearly showed that impaired gait in CNSLBP patients improved more in the CFT group than in the MSI group.Previously, Barzilay et al. (2016) [To support Barzilay’s study findings, we found the improvement of VGRF parameters with the improvement of pain, disability, and kinesiophobia. In CFT group we saw significant percentage of changes for pain (60.74%), disability (52.98%), and kinesiophonbia (44.6%) accompanied with the better improvement of VGRF parameters after prescribing eight-week multidimensional intervention. Also, significant percentage of changes for pain (44.23%), disability (50.15%), kinesiophonbia (36.73%) and improvement of VGRF parameters observed in CFT group six months after the first treatment.According to Krekoukias et.al [In this study patients in both experimental groups preferred to walk faster in post-test in both self-selected speed and faster speed, besides the push-off rate improved in both groups specially in CFT group. Therefore, it is likely cognitive functional therapy improved the dealing with perturbations and as a result progressed the push-off rate and gait speed.Patients with low back pain, showing higher electromyographic activity of the rectus abdominis and erector spinae during gait [In contrast to the physiological gait, the pelvis rotates in the opposite direction from the trunk, but low back pain patients demonstrated gait compensations that exhibit increased pelvic rotation with concurrent trunk rotation which is assumed for antalgic purposes [In this study, the CFT group showed better pain improvement compared to the MSI group, which may result in a greater reduction of these compensatory movements. The CFT group has demonstrated more progression in gait parameters.Other aspects include the influence doctors have on patient outcomes and treatment confirmation, including their communication skills, empathy and degree of trust [similar to our previous hypothesis, we can draw a conclusion that when patients received both psychological- and movement-based treatment that educated patients how to move better in their daily-routines, overcome their fear and change their beliefs toward a self-control management, they can perform better their functional tasks like walking with less fear of movement.This study has some limitations First, to better evaluate gait performance, researchers propose including not only VGRF but also the horizontal ground reaction forces. Second, the current study is limited by the lack of electromyography (EMG) in recording the functioning of core and abdominal muscles. Third, future studies should examine CFT intervention with other therapeutic methods, as it is currently compared with MSI treatment in this study. Fourth, this study based its sampling strategy on patients with chronic low back pain, which is defined as pain lasting for 90 days or more. Although the researchers selected pain intensity as the primary outcome measure, it should be noted that experts often recommend studies of patients with chronic pain to prioritize the primary outcome of disability, as pain intensity is more susceptible to regression to the mean. Despite using validated measurement tools and baseline assessments to minimize this potential limitation, the decision to make pain intensity the primary outcome may influence the overall interpretation of treatment efficacy. Finally, the lack of a translated and validated Persian version of Central Sensitization Inventory prevented us from assessing central sensitization. If we had used this tool, we could have determined whether there was any association between pain improvement and central sensitization in the studied population. For future similar studies, a translated and validated version of the Persian Central Sensitization Inventory will be beneficial, in addition to other pain intensity measures. For future studies, authors also suggest that random forest analysis with the Shapley Additive Explanations (SHAP) summary plot can present useful information regarding the rankings of major predictors and the directions of their associations with the superior effects of cognitive functional therapy.