Evidence for managing chronic low back pain in primary care: a review of recommendations from high-quality clinical practice guidelines

AIM

Chronic low back pain represents a major problem throughout the world which is increasing largely because of the aging world population. Clinical practice Guidelines can be powerful tools for promoting evidence-based practice, as they integrate research findings in order to support decision making. This study aimed to review recommendations for the management of Chronic low Back Pain in primary care based on high-quality recent and recently updated Clinical practice Guidelines.

METHODS

CINHAL, PubMed, EMBASE, PEDro, Google Scholar, Government websites, Scientific Association websites were searched until April 2019. The retrieved documents underwent several consecutive selection steps: semi-automated duplicate screening, documents selection based on title and abstract screening. Finally, three independent investigators screened the documents for the selected inclusion criteria and reviewed the retrieved documents by means of the AGREE II instrument.

RESULTS

A total of 3055 records were retrieved, of which 10 Clinical practice Guidelines met the inclusion criteria. The overall quality of these Clinical practice Guidelines was moderately variable. The recommendations of four Clinical practice Guidelines deemed as "excellent" were extracted and summarized. Although we tried to implement the most comprehensive research strategies, some Clinical practice Guidelines may be missing due to publication bias or incomplete indexing.

CONCLUSIONS

This study showed a partial progress in respect of the methodological quality of the Clinical practice Guidelines. Several AGREE II domains demonstrated low scores, particularly the "applicability" and "monitoring and auditing criteria" are the domains most susceptible to amendments in future.Implications for rehabilitationClinicians should be aware that among recently published/updated clinical practice guidelines for the management of chronic low back pain in primary care only few were deemed to have high quality.Increasing evidence suggests the efficacy for self-management to improve low back pain outcome.Physical treatments are recommended in order to improve low back pain outcome while many physical modalities such as TENS, ultrasound, laser therapy are not.Psychological treatments are recommended and should be included as part of a broader treatment plan.

Predicting outcomes within an innovative post-acute rehabilitation model for older adults

BACKGROUND

Understanding the provision of health services to community-dwelling older adults is of great importance due to regulatory changes within post-acute care. The aim of this study was to illustrate pathways by which older adults, within an innovative post-acute care delivery model, move to either independence or re-admission back into higher levels of care to maximize the value of rehabilitation delivery.

METHODS

Clinical data specific to an episode of care (n = 30,001) provided to Medicare beneficiaries treated via a rehabilitation house-calls model of care in their homes and senior living communites were separated into training and test sets. Classification trees were fit on the training set's administrative and clinical variables. Descriptive statistics were calculated for the overall sample, patient characteristics, clinical characteristics, and clinical outcomes.

RESULTS

Subjects were 83.3 years on average, 69.4% were female, and 62.2% were seen in their own homes while 37.8% were in senior living. The key variables predictive of progressing to independence were total number of visits, the presence of the Patient Specific Functional Scale (PSFS), PSFS score at discharge and change in PSFS. Prediction accuracy of the classification tree on the test set was 82.4%.

CONCLUSIONS

Older adults progress to a higher degree of independence, instead of higher levels of care, via several distinct pathways within a rehabilitation house-calls model of care. A mix of service utilization and outcome variables are key predictors of each pathway and may be used to maximize the value of service delivery. Further examination of the predictors of outcome using administrative datasets drawn from different sub-sets of older adults across the post-acute care continuum is warranted.

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

OBJECTIVE

To determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).

DESIGN

Convenience sample, prepilot and postpilot study.

SETTING

Human performance research laboratory.

PARTICIPANTS

Adults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.

INTERVENTIONS

Two 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.

MAIN OUTCOME MEASURES

Berg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.

RESULTS

Fourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.

CONCLUSION

This pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.

Left Ventricular Function Before and After Aerobic Exercise Training in Women With Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a chronic debilitating illness. The effects of vigorous aerobic exercise training (AET) on heart function in PAH are poorly understood.

METHODS

Eighteen women with PAH (aged 56.2 ± 8.8 yr, body mass index: 28.8 ± 7.3 kg/m) underwent 10 wk of vigorous AET. Cardiac function was observed at rest and peak exercise using bioelectrical impedance cardiography before and after the AET. Cardiac function was observed in a small PAH subset (n = 7) for 10 wk before beginning the AET. A cohort of sedentary women (n = 19) served as healthy controls.

RESULTS

Left ventricular ejection fraction (48 ± 9.2 vs 61.5 ± 13.3%, P = .034) and the systemic vascular resistance index (2258 ± 419.1 vs 2939 ± 962.4 dyn·sec/cm·m, P = .008) were lower at supine rest in the baseline PAH group versus the healthy group, as were peak exercise heart rate (140 ± 13.3 vs 170 ± 13.8 beats/min, P < .001) and systemic vascular resistance index (828 ± 141.1 vs 824 ± 300.9 dyn·sec/cm·m, P = .050) after controlling for age and heart rate. Systemic vascular resistance index measured at peak exercise decreased in the PAH group after AET (828 ± 141.1 vs 766 ± 139.6 dyn·sec/cm·m, P = .020). Left ventricular early diastolic filling ratio worsened in the PAH subset prior to AET (95.9 ± 19.4 vs 76.2 ± 18.9%, P = .043) and remained unchanged after AET.

CONCLUSION

Vigorous AET was not associated with significant declines in left ventricular systolic or diastolic function in women with PAH. Aerobic exercise training may be beneficial for reducing afterload and may preserve left ventricular diastolic function.

Optimization of Movement: A Dynamical Systems Approach to Movement Systems as Emergent Phenomena

The term "movement system" has been defined as "represent(ing) the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts."5 Although we do not dispute the advantage of defining the "movement system" as a physiological system, we contend that how the profession is identified with a monolithic "movement system" is imprudent. We contend that our scientific expertise regarding "movement optimization" should move forward by reconsidering how movement is produced (and potentially optimized) as a behavioral phenomenon in itself and abandon further attempts to promote "the movement system" with a purportedly unique and static label. We believe that reframing diagnosis is possible if there is a move away from an exclusive emphasis on classification of anatomical and physiological deviations from "normal" based on organismic constraints when such data yield, at best, an incomplete insight into functional performance that includes environmental and task constraints. The recent application of complex systems approaches to disciplines as diverse as medicine, biology, economics, and meteorology warrants thoughtful consideration of the potential benefits of incorporating similar advances in conceptualization of the central questions in physical therapy.

Validity, Reliability, and Responsiveness of the Spanish Version of the OPTIMAL Instrument

BACKGROUND

The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a self-report instrument developed to measure the ability to perform mobility actions.

OBJECTIVE

To validate a Spanish version of the OPTIMAL instrument.

DESIGN

Cross-cultural adaptation and validation study.

SETTING

Primary and specialized outpatient care settings.

PARTICIPANTS

Three hundred seven patients beginning physical therapy treatment and 30 subjects from the general population.

METHODS

A 2-part study was designed based on guidelines for cultural adaptation of patient-reported outcome measures.

OUTCOMES

Reliability was estimated by internal consistency (Cronbach α), SE of measurement, and test-retest reliability (intraclass correlation coefficient) at 2 weeks. Confirmatory factor analysis was performed to examine structural validity. The association with the Physical Functioning Subscale was assessed with Spearman correlation coefficients. OPTIMAL scores across different groups were compared with Mann-Whitney U and Kruskal-Wallis tests. Effect size, standardized response mean, and minimal detectable change were determined for responsiveness.

RESULTS

The Spanish version of the OPTIMAL instrument showed a similar structure to the original English questionnaire. Cronbach α was 0.95 for the difficulty and confidence scales. Intraclass correlation coefficient was 0.91 (95% CI 0.87-0.94) for the difficulty scale and 0.90 (95% CI 0.85-0.93) for the confidence scale. The SE of measurement was 5.11 for the difficulty scale and 6.54 for the confidence scale. The association with the Physical Functioning Subscale was strong and significant (P < .001). The 2 scales showed significantly different scores for each of the established patient groups. The effect size was 0.61 (95% CI 0.48-0.74) for the difficulty scale and 0.53 (95% CI 0.38-0.69) for the confidence scale. The standardized response mean was 0.97 (95% CI 0.78-1.13) for the difficulty scale and 0.76 (95% CI 0.48-1.01) for the confidence scale. The minimal detectable change, of a possible score of 100, was 14.2 for the difficulty scale and 18.1 for the confidence scale.

CONCLUSION

The Spanish version of the OPTIMAL has appropriate reliability, validity, and responsiveness and it is an adequate self-report instrument for the assessment of mobility actions.

LEVEL OF EVIDENCE

III.

Cervical Radiculopathy: Effectiveness of Adding Traction to Physical Therapy-A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cervical radiculopathy (CR) is a common cervical spine disorder. Cervical traction (CT) is a frequently recommended treatment for patients with CR.

PURPOSE

The purpose of this study was to conduct a review and meta-analysis of randomized controlled trials (RCTs) on the effect of CT combined with other physical therapy procedures versus physical therapy procedures alone on pain and disability.

DATA SOURCES

Data were obtained from COCHRANE Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science, and PEDro, from their inception to July 2016.

STUDY SELECTION

All RCTs on symptomatic adults with CR, without any restriction regarding publication time or language, were considered.

DATA EXTRACTION

Two reviewers selected the studies, conducted the quality assessment, and extracted the results. Meta-analysis employed a random-effects model. The evidence was assessed using GRADE criteria.

DATA SYNTHESIS

Five studies met the inclusion criteria. Mechanical traction had a significant effect on pain at short- and intermediate-terms (g = -0.85 [95% CI = -1.63 to -0.06] and g = -1.17 [95% CI = -2.25 to -0.10], respectively) and significant effects on disability at intermediate term (g = -1.05; 95% CI = -1.81 to -0.28). Manual traction had significant effects on pain at short- term (g = -0.85; 95% CI = -1.39 to -0.30).

LIMITATIONS

The most important limitation of the present work is the lack of homogeneity in CR diagnostic criteria among the included studies.

CONCLUSIONS

In light of these results, the current literature lends some support to the use of the mechanical and manual traction for CR in addition to other physical therapy procedures for pain reduction, but yielding lesser effects on function/disability.

Fatigability, oxygen uptake kinetics and muscle deoxygenation in incomplete spinal cord injury during treadmill walking

PURPOSE

The purpose of the present study was to characterize hypothesized relationships among fatigability and cardiorespiratory fitness in individuals with chronic motor-incomplete SCI (iSCI) during treadmill walking. The theoretical framework was that exacerbated fatigability would occur concomitantly with diminished cardiorespiratory fitness in people with iSCI.

METHODS

Subjects with iSCI (n = 8) and an able-bodied reference group (REF) (n = 8) completed a 6-min walking bout followed by a walking bout of 30-min or until volitional exhaustion, both at a self-selected walking speed. Fatigability was assessed using both perceived fatigability and performance fatigability measures. Pulmonary oxygen uptake kinetics (VO₂ on-kinetics) was measured breath-by-breath and changes in deoxygenated hemoglobin/myoglobin concentration (∆[HHb]) of the lateral gastrocnemius was measured by near-infrared spectroscopy. Adjustment of VO₂ and ∆[HHb] on-kinetics were modeled using a mono-exponential equation.

RESULTS

Perceived fatigability and performance fatigability were 52% and 44% greater in the iSCI group compared to the REF group (p = 0.003 and p = 0.004). Phase II time constant (τp) of VO₂ on-kinetics and ∆[HHb] ½ time during resting arterial occlusion were 55.4% and 16.3% slower in iSCI vs REF (p < 0.01 and p = 0.047, respectively).

CONCLUSIONS

The results of the present study may suggest that compromised O₂ delivery and/or utilization may have contributed to the severity of fatigability in these individuals with iSCI. The understanding of the extent to which fatigability and VO₂ and Δ[HHb] on-kinetics impacts locomotion after iSCI will assist in the future development of targeted interventions to enhance function.

Overground Locomotor Training in Spinal Cord Injury: A Performance-Based Framework

Background: Locomotor training (LT) is the most commonly used treatment to improve walking performance following spinal cord injury (SCI). The advancement of LT treatments requires the addition of integrative models accounting for the numerous systems responsible for the recovery of walking function following SCI. Objective: This perspective monograph aims to (a) describe a performance-based framework for overground LT (OLT), (b) describe principles of adaptation and motor learning used to inform OLT program design, and (c) present an example OLT program based on the proposed framework. Methods: Individuals with chronic motor-incomplete SCI (7 male, 1 female) classified according to the American Spinal Injury Association Impairment Scale (AIS) as C and D were included. OLT included two 90-minute sessions performed over 12 weeks for a total of 24 sessions. Outcomes measures included overground walking speed, walking economy, pulmonary oxygen uptake, and muscle oxygen extraction measured via near-infrared spectroscopy. Results: Preliminary findings demonstrate the potential of OLT, as describe here, to increase overground walking speed, improve walking economy, accelerate processes associated with oxygen delivery and utilization at the rest-to-work transition, and lower oxygen extraction requirements of skeletal muscle during walking in individuals with chronic motor-incomplete SCI. Conclusion: The proposed framework offers a valuable template for LT program design in both clinical and research settings. Further research is necessary to better understand the effects of OLT and how principles of specificity, progressive overload, and variation within the performance-based framework can be manipulated to maximize function, health, and quality of life in SCI.

THE ADOLESCENT MEASURE OF CONFIDENCE AND MUSCULOSKELETAL PERFORMANCE (AMCAMP): DEVELOPMENT AND INITIAL VALIDATION

BACKGROUND

Although the relationship of self-efficacy to sports performance is well established, little attention has been paid to self-efficacy in the movements or actions that are required to perform daily activities and prepare the individual to resume sports participation following an injury and associated period of rehabilitation. There are no instruments to measure self-confidence in movement validated in an adolescent population.

PURPOSE

The purpose of this paper is to report on the development of the AMCaMP, a self-report measure of confidence in movement and provide some initial evidence to support its use as a measure of confidence in movement.

METHODS

The AMCaMP was adapted from OPTIMAL, a self-report instrument that measures confidence in movement, which had been previously designed and validated in an adult population. Data were collected from 1,115 adolescent athletes from 12 outpatient physical therapy clinics in a single healthcare system.

RESULTS

Exploratory factor analysis of the 22 items of the AMCaMP using a test sample revealed a three factor structure (trunk, lower body, upper body). Confirmatory factor analysis using a validation sample demonstrated a similar model fit with the data. Reliability of scores on each of three clusters of items identified by factor analysis was assessed with coefficient alpha (range = 0.82 to 0.94), Standard Error of Measurement (1.38 to 2.74), and Minimum Detectable Change (3.83 to 7.6).

CONCLUSIONS

AMCaMP has acceptable psychometric properties for use in adolescents (ages 11 to 18) as a patient-centric outcome measure of confidence in movement abilities after rehabilitation.

LEVEL OF EVIDENCE

IV.

Rasch Analysis of the Italian version of Pain Catastrophizing Scale (PCS-I)

OBJECTIVE

The aim of this study was to investigate the psychometric properties of the Italian version of the Pain Catastrophizing Scale (PCS-I) in patients with chronic low back pain.

METHODS

In a cross sectional study a total of 150 subjects with chronic low back pain were included. The Italian translation of the PCS was administered to all subjects. The properties of the Italian version of the PCS were explored by a Rasch analysis.

RESULTS

The PCS-I, by means of few modifications, fitted the Rasch model and passed the independent t-test for a unidimensional scale. The response categories for item 2 ``I fell I can't go on'' needed to be collapsed from 4 to 3 levels. Only the item 7 ``I keep thinking to of other painful events'' showed fit residual that exceeded the chosen thresholds of ± 2.5. No Differential functioning (DIF) was observed for age, sex, marital status, BMI and smoking.

CONCLUSION

The Italian version of PCS, with the purposed modifications, seems to reflect a unidimensional construct of Pain Catastrophizing. The scale seemed to be quite robust across age, sex, marital status, BMI and smoking. Targeting of the scale was moderate. A raw score to metric conversion was proposed.

The accuracy of pain drawing in identifying psychological distress in low back pain-systematic review and meta-analysis of diagnostic studies

The aim of this systematic review and meta-analysis was to estimate the accuracy of qualitative pain drawings (PDs) in identifying psychological distress in subacute and chronic low back pain (LBP) patients. [Subjects and Methods] Data were obtained from searches of PubMed, EBSCO, Scopus, PsycINFO and ISI Web of Science from their inception to July 2014. Quality assessments of bias and applicability were conducted using the Quality of Diagnostic Accuracy Studies-2 (QUADAS-2). [Results] The summary estimates were: sensitivity=0.45 (95% CI 0.34, 0.61), specificity=0.66 (95% CI 0.53, 0.82), positive likelihood ratio=1.23 (95% CI 0.93, 1.62), negative likelihood ratio=0.84 (95% CI 0.70, 1.01), and diagnostic odds ratio=1.46 (95% CI 0.79, 2.68). The area under the curve was 78% (CI, 57 to 99%). [Conclusion] The results of this systematic review do not show broad and unqualified support for the accuracy of PDs in detecting psychological distress in subacute and chronic LBP.