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Kaija A Karjalainen

Bio: Kaija A Karjalainen is an academic researcher from Finnish Institute of Occupational Health. The author has contributed to research in topics: Rehabilitation & Low back pain. The author has an hindex of 13, co-authored 14 publications receiving 2522 citations.

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Journal ArticleDOI
23 Jun 2001-BMJ
TL;DR: Evidence is provided that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain and whether the improvements are worth the cost of these intensive treatments is unclear.
Abstract: Objective: To assess the effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain Design: Systematic literature review of randomised controlled trials Participants: A total of 1964 patients with disabling low back pain for more than three months Main outcome measures: Pain, function, employment, quality of life, and global assessments Results: Ten trials reported on a total of 12 randomised comparisons of multidisciplinary treatment and a control condition There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments There was moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain when compared with outpatient non-multidisciplinary rehabilitation or usual care There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves Less intensive outpatient psychophysical treatments did not improve pain, function, or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care Few trials reported effects on quality of life or global assessments Conclusions: The reviewed trials provide evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes What is already known on this topic Disabling chronic pain is regarded as the result of interrelating physical, psychological, and social or occupational factors requiring multidisciplinary intervention Two previous systematic reviews of multidisciplinary rehabilitation for chronic pain were open to bias and did not include any of the randomised controlled trials now available What this study adds Intensive, daily biopsychosocial rehabilitation with a functional restoration approach improves pain and function in chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes It is unclear whether the improvements are worth the cost of these intensive treatments

930 citations

Reference EntryDOI
TL;DR: There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments.
Abstract: Background Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies. Objectives To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain. Search strategy We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. Intervention specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration. Selection criteria Design: randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention. Population: Adults with disabling low back pain of more than three months in duration. Intervention: Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions. Outcomes: Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement. Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded. Data collection and analysis Selection, data extraction and quality grading of studies was done by two independent authors using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between authors were resolved by consensus or by a third author. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent. Main results Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments. Authors' conclusions The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.

378 citations

Reference EntryDOI
TL;DR: There was moderate scientific evidence showing that multidisciplinary rehabilitation, which includes a workplace visit or more comprehensive occupational health care intervention, helps patients to return to work faster, results in fewer sick leaves and alleviates subjective disability.
Abstract: Background Multidisciplinary biopsychosocial rehabilitation programs are widely applied for chronic low back pain patients. The biopsychosocial approach can also prevent chronicity, by providing rehabilitation for patients who still have pain past the initial acute phase. Nevertheless, multidisciplinary treatment programmes are often laborious and long processes and require good collaboration between the patient, the rehabilitation team and the work place. By using workplace visits and developing close relationships with occupational health care providers, one might expect patients' working ability to improve. Objectives The objective of this systematic review was to determine the effectiveness of multidisciplinary rehabilitation for subacute low back pain among working age adults. Search methods The reviewed studies for this review were electronically identified from MEDLINE, EMBASE, PsycLIT, CENTRAL, Medic, the Science Citation Index, reference checking and consulting experts in the rehabilitation field. The original search was planned and performed for the broader area of musculoskeletal disorders. Trials on subacute low back pain were separated afterwards. The literature search was last updated in November 2002 in EMBASE and MEDLINE. Selection criteria From all references identified in our original search, we selected randomised controlled trials (RCTs) and non-randomised controlled clinical trials (CCTs). Trials had to assess the effectiveness of multidisciplinary rehabilitation for working age patients suffering from subacute low back pain (more than four weeks but less than three months). The rehabilitation program was required to be multidisciplinary, i.e., it had to consist of a physician's consultation plus either a psychological, social or vocational intervention, or a combination of these. Data collection and analysis Four reviewers blinded to journal and author selected trials that met the specified inclusion criteria. Two experts in the field of rehabilitation evaluated the clinical relevance and applicability of the findings of the selected studies for actual clinical use. Two other reviewers blinded to journal and author extracted the data and assessed the main results and the methodological quality of the studies, using standardized forms. Finally, a qualitative analysis was performed to evaluate the level of scientific evidence for the effectiveness of multidisciplinary rehabilitation. Main results After screening 1808 abstracts, and the references of 65 reviews, we found only two relevant studies that satisfied our criteria on subacute low back pain. No more studies were found during the updates. Both studies were considered to be methodologically low quality RCTs. The clinical relevance of included studies was sufficient. There was moderate scientific evidence showing that multidisciplinary rehabilitation, which includes a workplace visit or more comprehensive occupational health care intervention, helps patients to return to work faster, results in fewer sick leaves and alleviates subjective disability. Authors' conclusions We conclude that there is moderate evidence of positive effectiveness of multidisciplinary rehabilitation for subacute low back pain and that a workplace visit increases the effectiveness. But because this evidence is based on trials that had some methodological shortcomings, and several expensive multidisciplinary rehabilitation programmes are commonly used for uncomplicated/non-specific subacute low back problems, there is an obvious need for high quality trials in this field.

264 citations

Journal ArticleDOI
TL;DR: There appears to be little scientific evidence for the effectiveness of multidisciplinary rehabilitation for these musculoskeletal disorders, but behavioral treatment and stress management appear to be important components.
Abstract: Background Non-malignant musculoskeletal pain is an increasing problem in western countries. Fibromyalgia syndrome is an increasing recognised chronic musculoskeletal disorder. Objectives The objective of this systematic review was to determine the effectiveness of multidisciplinary rehabilitation for fibromyalgia and widespread musculoskeletal pain among working age adults. Search methods An electronic search was conducted and included MEDLINE from 1966, PsycLIT from 1967 and EMBASE from 1980 to April 1998. The Cochrane Musculoskeletal Group Trials Register was searched as well as, the Cochrane Controlled Trials Register (CCTR). The references of identified articles and reviews were checked, studies published in the Finnish medical database Medic from 1978 to 1998 screened and the Science Citation Index searched. Content experts were also contacted for additional or unpublished studies. Selection criteria From all references found in our original search, we selected all randomized controlled trials (RCTs) and clinical controlled trials (CCTs). Trials had to assess the effectiveness of multidisciplinary rehabilitation for patients suffering from fibromyalgia and widespread musculoskeletal pain among working age adults. The rehabilitation program was required to be multidisciplinary; that is, it had to consist of a physician's consultation, plus a psychological, social or vocational intervention, or a combination of both. Data collection and analysis Four reviewers independently selected the RCTs and CCTs that met the specified inclusion criteria. Two experts in the field of rehabilitation evaluated the relevance and applicability of the findings of the selected studies to actual clinical use. Two other reviewers extracted the data and assessed the main results and the methodological quality of the studies using standardized forms. Finally, a qualitative analysis was performed to evaluate the level of scientific evidence for the effectiveness of multidisciplinary rehabilitation. Main results After screening 1808 abstracts, and the references of 65 reviews, we found only seven relevant studies (1050 patients) that met our inclusion criteria. None of these were considered, methodologically, a high quality randomized controlled trial. Four of the included RCTs on fibromyalgia were graded low quality and suggest no quantifiable benefits. The three included RCTs on widespread musculoskeletal pain showed that based on limited evidence, overall, no evidence of efficacy was observed. However, behavioral treatment and stress management appear to be important components. Education combined with physical training showed some positive effects in long term follow up. Authors' conclusions We conclude that there appears to be little scientific evidence for the effectiveness of multidisciplinary rehabilitation for these musculoskeletal disorders. However, multidisciplinary rehabilitation is a commonly used intervention for chronic musculoskeletal disorders, which cause much personal suffering and substantial economic loss to the society. There is a need for high quality trials in this field.

207 citations

Journal ArticleDOI
TL;DR: It is concluded that there appears to be little scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation facilities on neck and shoulder pain.
Abstract: Background Multidisciplinary biopsychosocial rehabilitation programs for neck and shoulder pain require substantial staff and financial resources. Despite questionable scientific evidence of their effectiveness, they are widely used. Neck and shoulder complaints are common among working age adults and they are often associated with physical work load and stress. Pain in the neck and shoulder area cause biopsychosocial difficulties for the patient, especially if disability due to pain is prolonged. To help patients with biopsychosocial problems, or to prevent their development, multidisciplinary biopsychosocial programs are used for rehabilitation for patients with neck and shoulder pain. Nevertheless, multidisciplinary treatment programmes are often laborious and rather long processes and require good collaboration between the patient, the rehabilitation team and the work place. Objectives The objective of this systematic review was to determine the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Search methods The reviewed studies for this review were electronically identified from MEDLINE, EMBASE, PsycLIT, CENTRAL, Medic, the Science Citation Index, reference checking and consulting experts in the rehabilitation field. The original search was planned and performed for more broad area of musculoskeletal disorders. Trials on neck and shoulder pain were separated afterwards. The literature search was updated in November 2002 by electronically searching MEDLINE and EMBASE. Selection criteria From all references identified in our original search, we selected randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs). Trials had to assess the effectiveness of biopsychosocial rehabilitation for working age adults suffering from neck and shoulder pain. The rehabilitation program was required to be multidisciplinary, i.e., it had to consist of a physician's consultation plus either a psychological, social or vocational intervention, or a combination of these. Data collection and analysis Four authors blinded to journal and author selected the trials that met the specified inclusion criteria. Two experts in the field of rehabilitation evaluated the clinical relevance and applicability of the findings of the selected studies for actual clinical use. Two other authors blinded to journal and author extracted the data and assessed the main results and the methodological quality of the studies, using standardized forms. Finally, a qualitative analysis was performed to evaluate the level of scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation. Main results After screening 1808 abstracts, and the references of 65 reviews, we found only two relevant studies that satisfied our criteria. No more studies were found for this update. One of the studies was considered to be a methodologically low quality RCT and the other one was a methodologically low quality CCT. The clinical relevance of included studies was satisfactory. There was limited scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain. Authors' conclusions We conclude that there appears to be little scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation facilities for neck and shoulder pain. Multidisciplinary rehabilitation is a commonly used intervention for chronic neck and shoulder complaints, therefore we see an urgent need for high quality trials in this field.

180 citations


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Journal ArticleDOI
TL;DR: This guideline is to present the available evidence for evaluation and management of acute and chronic low back pain in primary care settings and grades its recommendations by using the ACP's clinical practice guidelines grading system.
Abstract: Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

2,416 citations

Journal ArticleDOI
15 Jun 2003-Spine
TL;DR: The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis, and additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions.
Abstract: Study design Descriptive method guidelines. Objectives To help reviewers design, conduct, and report reviews of trials in the field of back and neck pain. Summary of background data In 1997, the Cochrane Collaboration Back Review Group published method guidelines for systematic reviews. Since its publication, new methodologic evidence emerged and more experience was acquired in conducting reviews. Methods All reviews and protocols of the Back Review Group were assessed for compliance with the 1997 method guidelines. Also, the most recent version of the Cochrane Handbook (4.1) was checked for new recommendations. In addition, some important topics that were not addressed in the 1997 method guidelines were included (e.g., methods for qualitative analysis, reporting of conclusions, and discussion of clinical relevance of the results). In May 2002, preliminary results were presented and discussed in a workshop. In two rounds, a list of all possible recommendations and the final draft were circulated for comments among the editors of the Back Review Group. Results The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis. Each recommendation is classified in minimum criteria and further guidance. Additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions. Conclusions Systematic reviews need to be conducted as carefully as the trials they report and, to achieve full impact, systematic reviews need to meet high methodologic standards.

1,974 citations

Journal ArticleDOI
TL;DR: The current state of scientific evidence for the individual components of the fear-avoidance model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities is reviewed.
Abstract: Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.

1,900 citations