BackgroundPeople who suffer from low back pain (LBP) exhibit an abnormal gait pattern, characterized by shorter stride length, greater step width, and an impaired thorax-pelvis coordination which may undermine functional walking. As a result, gait in LBP may require stronger cognitive regulation compared to pain free subjects thereby affecting the degree of automaticity of gait control. Conversely, because chronic pain has a strong attentional component, diverting attention away from the pain might facilitate a more efficient walking pattern.MethodsTwelve individuals with LBP and fourteen controls participated. Subjects walked on a treadmill at comfortable speed, under varying conditions of attentional load: (a) no secondary task, (b) naming the colors of squares on a screen, (c) naming the colors of color words ("color Stroop task"), and (d) naming the colors of words depicting motor activities. Markers were attached to the thorax, pelvis and feet. Motion was recorded using a three-camera SIMI system with a sample frequency of 100 Hz. To examine the effects of health status and attention on gait, mean and variability of stride parameters were calculated. The coordination between thoracic and pelvic rotations was quantified through the mean and variability of the relative phase between those oscillations.ResultsLBP sufferers had a lower walking speed, and consequently a smaller stride length and lower mean thorax-pelvis relative phase. Stride length variability was significantly lower in the LBP group but no significant effect of attention was observed. In both groups gait adaptations were found under performance of an attention demanding task, but significantly more so in individuals with LBP as indicated by an interaction effect on relative phase variability.ConclusionGait in LBP sufferers was characterized by less variable upper body movements. The diminished flexibility in trunk coordination was aggravated under the influence of an attention demanding task. This provides further evidence that individuals with LBP tighten their gait control, and this suggests a stronger cognitive regulation of gait coordination in LBP. These changes in gait coordination reduce the capability to deal with unexpected perturbations, and are therefore maladaptive.

Objectives. The aim of this trial was to evaluate the difference in treatment effect, at 26 and 52 weeks after the start of treatment, between cognitive behavioural therapy (CBT) and multidisciplinary rehabilitation treatment (MRT) for patients with chronic fatigue syndrome (CFS).Design. Multicentre, randomized controlled trial of patients with CFS. Participants were randomly assigned to MRT or CBT.Setting. Four rehabilitation centres in the Netherlands. Subjects. A total of 122 patients participated in the trial.Main outcome measures. Primary outcomes were fatigue measured by the fatigue subscale of the Checklist Individual Strength and health-related quality of life measured by the Short-Form 36. Outcomes were assessed prior to treatment and at 26 and 52 weeks after treatment initiation.Results. A total of 114 participants completed the assessment at 26 weeks, and 112 completed the assessment at 52 weeks. MRT was significantly more effective than CBT in reducing fatigue at 52 weeks. The estimated difference in fatigue between the two treatments was À3.02 [95% confidence interval (CI) À8.07 to 2.03; P = 0.24] at 26 weeks and À5.69 (95% CI À10.62 to À0.76; P = 0.02) at 52 weeks. Patients showed an improvement in quality of life over time, but between-group differences were not significant. Conclusion.This study provides evidence that MRT is more effective in reducing long-term fatigue severity than CBT in patients with CFS. Although implementation in comparable populations can be recommended based on clinical effectiveness, it is advisable to analyse the cost-effectiveness and replicate these findings in another multicentre trial.

No clinical meaningful differences were found between treatment conditions in the primary outcome measures health-related quality of life and disability. However, this is the first long-term RCT that has shown that PMT improves BA in patients with chronic pain and shows good effect size and a significant decrease for catastrophizing.

BackgroundA multi-centre RCT has shown that multidisciplinary rehabilitation treatment (MRT) is more effective in reducing fatigue over the long-term in comparison with cognitive behavioural therapy (CBT) for patients with chronic fatigue syndrome (CFS), but evidence on its cost-effectiveness is lacking.AimTo compare the cost-effectiveness of MRT versus CBT for patients with CFS from a societal perspective.MethodsA multi-centre randomized controlled trial comparing MRT with CBT was conducted among 122 patients with CFS diagnosed using the 1994 criteria of the Centers for Disease Control and Prevention and aged between 18 and 60 years. The societal costs (healthcare costs, patient and family costs, and costs for loss of productivity), fatigue severity, quality of life, quality-adjusted life-year (QALY), and cost-effectiveness ratios (ICERs) were measured over a follow-up period of one year. The main outcome of the cost-effectiveness analysis was fatigue measured by the Checklist Individual Strength (CIS). The main outcome of the cost-utility analysis was the QALY based on the EuroQol-5D-3L utilities. Sensitivity analyses were performed, and uncertainty was calculated using the cost-effectiveness acceptability curves and cost-effectiveness planes.ResultsThe data of 109 patients (57 MRT and 52 CBT) were analyzed. MRT was significantly more effective in reducing fatigue at 52 weeks. The mean difference in QALY between the treatments was not significant (0.09, 95% CI: -0.02 to 0.19). The total societal costs were significantly higher for patients allocated to MRT (a difference of €5,389, 95% CI: 2,488 to 8,091). MRT has a high probability of being the most cost effective, using fatigue as the primary outcome. The ICER is €856 per unit of the CIS fatigue subscale. The results of the cost-utility analysis, using the QALY, indicate that the CBT had a higher likelihood of being more cost-effective.ConclusionsThe probability of being more cost-effective is higher for MRT when using fatigue as primary outcome variable. Using QALY as the primary outcome, CBT has the highest probability of being more cost-effective.Trial registrationISRCTN77567702.

tion programmes, which are based on physical training and behavioural cognitive training, is to improve the health-related quality of life of patients by coaching them to cope with their pain and its consequences (1). Drop-out from low back pain rehabilitation of non-native patients (28.1%) in the Netherlands has been reported to be twice as high as in native Dutch patients (13.7%); the overall drop-out rate is 18.7% (2). The higher drop-out rate of non-native patients is consistent with a study conducted in mental healthcare. In that study the drop-out rate was significantly higher in ethnic minority patients (52%) compared with native patients (30%) (3). Furthermore, the overall drop-out rate in patients with low back pain (18.7%) (2) is consistent with those of previous studies in patients with (low back) pain, which found drop-out rates ranging from 10% to 42% (4-6).There is, however, limited knowledge of the causes of this higher drop-out rate in non-native patients. In a qualitative study, sources of tension in the interaction between non-native patients and native Dutch physicians in chronic non-specific low back pain rehabilitation treatment have been identified (7). These sources of tension, found directly after the first consultation with the rehabilitation physician, were: patients expecting a specific diagnosis and pain relief as the primary aims of treatment; more explicit symptom presentation of patients; different views on responsibilities with regard to the rehabilitation treatment (physicians implied that patients expected more responsibility to be taken by the physician); lack of trust in the rehabilitation physician; contradicting views given by physicians from the patients' country of origin with regard to the cause and treatment of pain; and communication problems, partly due to shame and embarrassment about patients' limited language proficiency in Dutch. These sources of tension potentially lead to future drop-out.More sick leave days (4, 8, 9), higher pain severity (9, 10), being less active in sports (4), a lower age (9) and the idea that exercise did not help or aggravated pain (11) have been identified as predictors of drop-out in low back pain rehabilitation programmes. A systematic review of qualitative and quantitative studies in patients with low back pain regarding INTRODUCTIONPatients with chronic non-specific low back pain can benefit from rehabilitation programmes. The aim of these rehabilita- 567Reasons for drop-out from rehabilitation their expectations and satisfaction with treatment (12) showed that patients in general (i.e. not specifically selected for a non-native background) are dissatisfied with low back pain treatment for a number of reasons, including: not obtaining a specific diagnosis of the pain; pain relief not being the main aim of treatment; lack of physical examination and diagnostic tests; lack of referrals to other therapy or specialists for further treatment; no possibility of sickness certification. This review study seems to show that patients with low ...

BackgroundPatients with chronic fatigue syndrome experience extreme fatigue, which often leads to substantial limitations of occupational, educational, social and personal activities. Currently, there is no consensus regarding the treatment. Patients try many different therapies to overcome their fatigue. Although there is no consensus, cognitive behavioural therapy is seen as one of the most effective treatments. Little is known about multidisciplinary rehabilitation treatment, a combination of cognitive behavioural therapy with principles of mindfulness, gradual increase of activities, body awareness therapy and pacing. The difference in effectiveness and cost-effectiveness between multidisciplinary rehabilitation treatment and cognitive behavioural therapy is as yet unknown. The FatiGo (Fatigue-Go) trial aims to compare the effects of both treatment approaches in outpatient rehabilitation on fatigue severity and quality of life in patients with chronic fatigue syndrome.MethodsOne hundred twenty patients who meet the criteria of chronic fatigue syndrome, fulfil the inclusion criteria and sign the informed consent form will be recruited. Both treatments take 6 months to complete. The outcome will be assessed at 6 and 12 months after the start of treatment. Two weeks after the start of treatment, expectancy and credibility will be measured, and patients will be asked to write down their personal goals and score their current performance on these goals on a visual analogue scale. At 6 and 14 weeks after the start of treatment, the primary outcome and three potential mediators—self-efficacy, causal attributions and present-centred attention-awareness—will be measured. Primary outcomes are fatigue severity and quality of life. Secondary outcomes are physical activity, psychological symptoms, self-efficacy, causal attributions, impact of disease on emotional and physical functioning, present-centred attention-awareness, life satisfaction, patient personal goals, self-rated improvement and economic costs. The primary analysis will be based on intention to treat, and longitudinal analysis of covariance will be used to compare treatments.DiscussionThe results of the trial will provide information on the effects of cognitive behavioural therapy and multidisciplinary rehabilitation treatment at 6 and 12 months follow-up, mediators of the outcome, cost-effectiveness, cost-utility, and the influence of treatment expectancy and credibility on the effectiveness of both treatments in patients with chronic fatigue syndrome.Trial registrationCurrent Controlled Trials ISRCTN77567702.

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