Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

A multicenter feasibility randomized controlled trial using a virtual reality application of pain neuroscience education for adults with chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) is a highly prevalent condition among adults and is correlated to high levels of pain, high disability, and lower quality of life. Pain neuroscience education (PNE) helps to explain the pain experience and can affect psychosocial factors, such as fear of movement, anxiety, socioeconomic status, work life satisfaction, etc. More recently, virtual reality (VR) programs have emerged allowing for immersive PNE experiences.

OBJECTIVE

The purpose of this randomized clinical trial is to determine the feasibility of using a VR application for the delivery of immersive PNE (VR-PNE) and other activity training for patients with CLBP presenting to outpatient physical therapy (PT) clinics.

METHODS

A two-arm, parallel group, randomized controlled feasibility trial of patients was conducted at 12 outpatient PT clinics from March 9, 2022, through September 9, 2022. The intervention group received PT as usual and VR-PNE while the control group received PT as usual. Between group feasibility, acceptability outcomes and other patient-reported outcomes were assessed at six weeks.

RESULTS

A total of 595 individuals were evaluated for low back pain during the recruitment period. Seventy individuals were eligible and met definition for CLBP, 52 enrolled and 32 completed the trial. Participant adherence was 63.6% for VR-PNE and 63.2% for PT as usual. Participants found VR-PNE acceptable and reported satisfaction scores (0-100) of 87.37 ± 11.05 compared to 81.17 ± 23.72 in the PT as usual group. There were no significant differences between groups for the BBQ, BRS, FABQ-PA, FABQ-W, GROC, NPRS, NPQ, PCS, and PSEQ at 6 weeks.

CONCLUSION

The results of the trial suggest that VR-PNE may be acceptable and feasible for patients with CLBP. Study procedures and PT delivery modifications should be considered for the next iteration of this study to improve follow-up assessment rates.

Physiotherapists' attitudes and beliefs in the management of low back pain: Protocol for a systematic review

BACKGROUND

Low back pain (LBP) poses a significant global health burden where a biopsychosocial model of care has been recommended. Physiotherapists (PTs) play a crucial role in LBP management; however, their attitudes and beliefs towards LBP were not reviewed in detail.

OBJECTIVE

This systematic review aims to summarise the attitudes and beliefs of PTs towards LBP and the factors influencing them.

METHODS

The review protocol and methods adhere to the PRISMA-P and Meta Analyses and Systematic Reviews for Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search of PubMed, Scopus, CINAHL, Web of Science, PEDro and Ovid databases will be conducted to search for cross-sectional studies evaluating PTs' attitudes and beliefs towards LBP. Two reviewers will independently screen the articles, conduct data extraction and assess methodological quality using the Joanna Briggs Institute's critical appraisal tool for prevalence studies. Data synthesis will involve a narrative synthesis of study characteristics, attitudes, beliefs, and methodological quality. If feasible, a meta-analysis will be performed to quantify the pooled effects.

CONCLUSION

Despite the emphasis on biopsychosocial approaches for managing LBP, the adoption of such approaches in physiotherapy practice is still suboptimal, with attitudes and beliefs of PTs being considered an important factor influencing treatment practices. Our review will summarise the literature on attitudes and beliefs of PTs towards LBP. Such knowledge would inform the need for development of additional interventions addressing the attitudes and beliefs that would eventually enhance the update of the biopsychosocial model of care in physiotherapy management of LBP.

Beliefs and practice patterns of spinal thrust manipulation for mechanical low back pain of physical therapists in the state of Minnesota

INTRODUCTION

The primary purpose of this study was to examine the perceptions and utilization of spinal thrust manipulation (STM) techniques of physical therapists who treat patients with low back pain (LBP) in the State of Minnesota. A secondary purpose was to investigate differences between physical therapists who perform STM and those who do not.

METHODS

A cross-sectional design was utilized through the completion of an electronic survey. 74 respondents completed the survey. Descriptive measures were recorded as frequencies for categorical data or mean ± standard deviation for continuous data. For between-group comparisons, chi-square analyses were used for categorical items of nominal or ordinal data and t-tests were utilized for continuous data. The alpha level was set at p < 0.05.

RESULT

60.2% of respondents reported using STM when treating patients with LBP. 69.9% of respondents utilize a classification system. 76.7% of individuals answered correctly regarding the Minnesota State practice act. Of those who use STM, 81.8% utilize a Clinical Prediction Rule. Respondents who use STM were more likely to have a specialist certification (chi-square = 6.471, p = 0.011) and to have completed continuing education courses on manual therapy (chi-square = 4.736, p = 0.030).

DISCUSSION/CONCLUSIONS

Physical therapists who perform STM are more likely to have a better understanding of their state practice act, be board certified, and have completed continuing education in manual therapy.

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

Chronic primary low back pain (CPLBP) refers to low back pain that persists over 3 months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective in relieving CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n = 49) or a control intervention (n = 49), 12 times over 4 weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in 4 body regions, pain catastrophizing, Central Sensitization Inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (P < .001) and higher scores for all questionnaires (P < .001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% confidence interval, -11.0 to -12.5], P = .01), but not disability (P = .5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (P < .05). Pain catastrophizing was reduced after SMT compared with the control intervention (P < .05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE: This randomized controlled trial found that 12 sessions of SMT yield greater relief of CPLBP than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.

Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians' views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Methods

An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials.

Results

There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%).

Conclusion

This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK.

How is cognitive behavioural therapy for insomnia delivered to adults with comorbid persistent musculoskeletal pain and disordered sleep? A scoping review

BACKGROUND

Disordered sleep and persistent musculoskeletal pain are highly comorbid. Behavioural interventions such as Cognitive Behavioural Therapy for Insomnia (CBT-I) have shown promise in the management of both disordered sleep and persistent musculoskeletal pain. The aim of this review was to examine how CBT-I is delivered in randomised controlled trials involving people with comorbid disordered sleep and persistent musculoskeletal pain.

METHODS

The protocol for this scoping review was registered with the Open Science Framework. Electronic searches of ten database and three clinical trials registries were performed up to 25 October 2023. The methodological quality of each study was evaluated by two independent reviewers using the PEDro tool. The reporting of CBT-I interventions was evaluated using the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Twelve studies met the eligibility criteria. TIDieR scores ranged from 7-11/12, with a mean score of 8.8/12. CBT-I always involved two core components-sleep restriction and stimulus control. Furthermore, an additional five components were usually involved-a cognitive component, sleep hygiene, sleep education, relaxation/deactivation procedures and relapse planning. There was also considerable consistency in the frequency (weekly) and duration (5-9 weeks) of CBT-I programmes. Aspects inconsistently reported included who delivered the intervention; what modifications were made, if any; and the session content and duration. PEDro scores ranged from 5-8/10, with a mean score of 6.7/10.

CONCLUSIONS

These findings demonstrate considerable consistency in the components of CBT-I delivered in clinical trials along with the number of sessions. The frequency of sessions was also consistent where almost all studies held weekly session. However, some aspects were either not reported (e.g., precise content of components) or inconsistent (e.g., use of terminology). CBT-I was delivered both individually and in groups. Greater consistency, and more detailed reporting regarding who delivered the intervention, the training provided, and the specific content of CBT-I components would add clarity, and may enhance CBT-I efficacy and allow better replication.

Assessing the transparency in reporting of clinical trials investigating manual therapy interventions for low back pain: A methodological review

RATIONALE

Low back pain (LBP) is a common condition with a significant societal burden. Manual therapy is an effective treatment for LBP and recommended in clinical practice guidelines. While the quantity of literature supporting the use of manual therapy is large, the methodological quality and transparency of this collective work are unclear.

AIMS AND OBJECTIVES

Explore the transparency in reporting of clinical trials assessing manual therapy interventions in patients with LBP by comparing planned components in the trial registration with what was reported in the published manuscript.

METHODS

Three databases were searched to identify trials assessing the treatment effect of manual therapy for LBP from January 2005 to May 2023. Studies were included if the manual therapy consisted of thrust manipulations, mobilizations or muscle energy techniques.

RESULTS

From 4462 studies initially identified, 167 studies remained in the final review after title, abstract and full-text review. Only 87 (52.1%) of the 167 studies were registered (n = 57 prospectively and n = 30 retrospectively). Primary outcomes in the publications were identical to the registration in 54 (62.1%) of the registered trials. Secondary outcomes in the publication were identical to the registration in 27 (31.0%) of the registered trials. The CONSORT reporting guideline was referenced in only 19 (21.8%) trials. Multiple discrepancies between registration and publication were noted for primary and secondary outcomes. All trials had eligibility criteria in the registration that matched their corresponding manuscript, while only four (4.6%) trial registrations addressed any type of statistical analysis plan.

CONCLUSION

Approximately half of the trials were not registered. Of those registered, only half were registered prospectively. Substantial discrepancies existed between registered and published outcomes that were never addressed by the authors, raising questions about potential bias. Transparency can be improved through more stringent requirements during manuscript submission to journals, and better reporting of the rationale for discrepancies between registration and publication.

Effects of combined anodal transcranial direct current stimulation and motor control exercise on cortical topography and muscle activation in individuals with chronic low back pain: A randomized controlled study

BACKGROUND

Aberrant movement in chronic low back pain (CLBP) is associated with a deficit in the lumbar multifidus (LM) and changes in cortical topography. Anodal transcranial direct current stimulation (a-tDCS) can be used to enhance cortical excitability by priming the neuromuscular system for motor control exercise (MCE), thereby enhancing LM activation and movement control. This study aimed to determine the effects of a 6-week MCE program combined with a-tDCS on cortical topography, LM activation, movement patterns, and clinical outcomes in individuals with CLBP.

METHODS

Twenty-two individuals with CLBP were randomly allocated to the a-tDCS group (a-tDCS; n = 12) or sham-tDCS group (s-tDCS; n = 10). Both groups received 20 min of tDCS followed by 30 min of MCE. The LM and erector spinae (ES) cortical topography, LM activation, movement control battery tests, and clinical outcomes (disability and quality of life) were measured pre- and post-intervention.

RESULTS

Significant interaction (group × time; p < 0.01) was found in the distance between LM and ES cortical locations. The a-tDCS group demonstrated significantly fewer discrete peaks (p < 0.05) in both ES and LM and significant improvements (p < 0.05) in clinical outcomes post-intervention. The s-tDCS group demonstrated a significant increase (p < 0.05) in the number of discrete peaks in the LM cortical topography. No significant changes (p > 0.05) in LM activation were observed in either group; however, both groups demonstrated improved movement patterns.

DISCUSSION

Our findings suggest that combined a-tDCS with MCE can separate LM and ES locations over time while s-tDCS (MCE alone) reduces the distance. Our study did not find superior benefits of adding a-tDCS before MCE for LM activation, movement patterns, or clinical outcomes.

The pain attitudes and beliefs scale for physiotherapists: development and psychometric assessment of the Spanish version among physiotherapy students

INTRODUCTION

Pain might be approached from a biomedical or biopsychosocial perspective. There is a lack of research on the attitudes and beliefs about pain among physiotherapy students. In this context, the Pain Attitudes and Belief Scale for Physiotherapists (PABS-PT) is an instrument widely used from a clinical and educational perspective, but its psychometric properties have not yet been tested in a student-based population.

OBJECTIVE

To develop the Spanish version of the PABS-PT scale and to assess its psychometric properties among students in physiotherapy.

METHODS

The study was carried out among 103 students in their final years of academic studies in the Degree in Physiotherapy in the University of Murcia (Spain). Sociodemographic and PABS-PT related variables were collected. The instrument was translated into Spanish and tested through factor analysis, internal consistency, test-retest reliability, and known-groups validity. The 95% minimal detectable change of the instrument was also calculated.

RESULTS

The factor analysis revealed two factors within the instrument: Biomedical (9 items) and Biopsychosocial (7 items) factors, with Cronbach's alpha values of 0.730 and 0.708, respectively. The Intraclass Correlation Coefficient (3,2) was 0.851 for the Biomedical factor and 0.699 for the Biopsychosocial factor. The minimal detectable changes (95% CI) for the Biomedical and Biopsychosocial factors were 6.01 and 5.56, respectively. The pre-specified hypothesis for the known-groups validity test was met and revealed large effect sizes (d = 1.24).

CONCLUSION

The Spanish version of the instrument PABS-PT-SP covers two factors. It shows satisfactory psychometric properties and it is therefore an effective framework to discriminate between the biomedical and/or biopsychosocial thoughts and attitudes toward pain in physiotherapy.

Identifying the risk of exercises, recommended by an artificial intelligence for patients with musculoskeletal disorders

Musculoskeletal disorders (MSDs) impact people globally, cause occupational illness and reduce productivity. Exercise therapy is the gold standard treatment for MSDs and can be provided by physiotherapists and/or also via mobile apps. Apart from the obvious differences between physiotherapists and mobile apps regarding communication, empathy and physical touch, mobile apps potentially offer less personalized exercises. The use of artificial intelligence (AI) may overcome this issue by processing different pain parameters, comorbidities and patient-specific lifestyle factors and thereby enabling individually adapted exercise therapy. The aim of this study is to investigate the risks of AI-recommended strength, mobility and release exercises for people with MSDs, using physiotherapist risk assessment and retrospective consideration of patient feedback on risk and non-risk exercises. 80 patients with various MSDs received exercise recommendations from the AI-system. Physiotherapists rated exercises as risk or non-risk, based on patient information, e.g. pain intensity (NRS), pain quality, pain location, work type. The analysis of physiotherapists' agreement was based on the frequencies of mentioned risk, the percentage distribution and the Fleiss- or Cohens-Kappa. After completion of the exercises, the patients provided feedback for each exercise on an 11-point Likert scale., e.g. the feedback question for release exercises was "How did the stretch feel to you?" with the answer options ranging from "painful (0 points)" to "not noticeable (10 points)". The statistical analysis was carried out separately for the three types of exercises. For this, an independent t-test was performed. 20 physiotherapists assessed 80 patient examples, receiving a total of 944 exercises. In a three-way agreement of the physiotherapists, 0.08% of the exercises were judged as having a potential risk of increasing patients' pain. The evaluation showed 90.5% agreement, that exercises had no risk. Exercises that were considered by physiotherapists to be potentially risky for patients also received lower feedback ratings from patients. For the 'release' exercise type, risk exercises received lower feedback, indicating that the patient felt more pain (risk: 4.65 (1.88), non-risk: 5.56 (1.88)). The study shows that AI can recommend almost risk-free exercises for patients with MSDs, which is an effective way to create individualized exercise plans without putting patients at risk for higher pain intensity or discomfort. In addition, the study shows significant agreement between physiotherapists in the risk assessment of AI-recommended exercises and highlights the importance of considering individual patient perspectives for treatment planning. The extent to which other aspects of face-to-face physiotherapy, such as communication and education, provide additional benefits beyond the individualization of exercises compared to AI and app-based exercises should be further investigated.Trial registration: 30.12.2021 via OSF Registries, https://doi.org/10.17605/OSF.IO/YCNJQ .

CPM-Related Mechanisms Could Play a Key Role in the Effects on Pain Sensitivity Induced by Manual Therapy: Three Crossover Trials Investigating the Effects of Manual Pressure

Objective: The aim of this study is to assess whether pain-inducing manual pressure (PIMP) leads to effects on pressure pain threshold (PPT) mediated by conditioned pain modulation (CPM) and whether these effects are influenced by the intensity and repetition of the stimulus. Additionally, the influence of psychological factors and physical activity on the response to PIMP was explored. Methods: A total of 72 pain-free students were randomly assigned to three crossover trials. Trial 1 compared the effects of PIMP with the cold pressor task and pain-inducing electrostimulation. Trial 2 compared the effects of manual pressure that elicited moderate pain, mild pain, and no pain. Trial 3 compared a single PIMP stimulation with four stimuli applied at the same site or at different sites. Results: PIMP produced a lower increase in PPT than cold pressor task and no difference with electrostimulation. Manual pressure that caused moderate pain led to a greater increase in PPT compared to mild pain and pain-free application. Repetition of PIMP stimulus, whether at the same or different sites, did not significantly increase PPT compared to a single stimulation. No association with psychological factors or physical activity was found. Conclusions: PIMP produces an increase in PPT, suggesting the involvement of CPM-related mechanisms.

Gamified delivery of at-home rehabilitation for individuals with nonspecific low back pain: a randomized controlled trial

PURPOSE

To measure the change in pain and disability during and after a 6-week gamified delivery of home exercise compared to a take-home packet.

MATERIALS AND METHODS

A 6-week at-home exercise protocol included participants randomly allocated to a gamified delivery group or packet group. The exercise protocol included the plank, side plank, foot elevated side plank, dead bug, and bird dog completed until discontinuation. The gamified delivery group received on-demand exercise videos and weekly exercise duration leaderboards. The packet group received a take-home packet.

RESULTS

Forty participants were randomized into a packet group and leaderboard group, and 30 participants completed the study. Disability was significantly lower at 6-weeks (11.29 ± 9.81%) compared to baseline (15.93 ± 11.65%) in the packet group (χ2(2) =10.89, Z= -3.163, p=.002, r=.708). Percent disability was significantly lower at 6-weeks (8.00 ± 5.91%) compared to baseline (13.01 ± 7.17%) in the gamified delivery group (χ2(2) =13.235, Z= -3.399, p= <.001, r= -0.760). Worst pain was higher at baseline (7.05 ± 1.61%) than at 6-weeks (5.75 ± 1.68%) in the packet group (χ2(2) =8.067, Z = 2.760, p=.006, r= -0.617). Worst pain was higher at baseline (6.90 ± 1.33%) than at 6-weeks (5.24 ± 2.38%) in the gamified delivery group (χ2(2) =6.250, Z= -2.810, p=.005, r= -0.628). No significant difference in the change of disability from baseline to 6 weeks was found between groups (p=.483).

CONCLUSIONS

Core exercises completed until failure may improve disability and pain at 6-weeks and positively influence perceived patient improvement.Registry: Clinicaltrials.gov; Registration number: NCT05573932.

The Efficacy of the Smartphone App for the Self-Management of Low Back Pain: A Systematic Review and Assessment of Their Quality through the Mobile Application Rating Scale (MARS) in Italy

Smartphone apps for self-management are valuable tools to help manage low back pain (LBP) patients. The purposes of this systematic review were to (a) summarize the available studies on the efficacy of smartphone apps for self-management of LBP and (b) identify free applications available in Italy that offer strategies for LBP self-management and provide a qualitative assessment using the Mobile Application Rating Scale (MARS). According to the Prisma Checklist, six bibliographic databases were searched with the keywords 'low back pain', 'mobile application', 'smartphone', and 'telemedicine'. In total, 852 records were screened, and 16 were included in the systematic review. Of the six RCTs included, four reported a statistically significant decrease in pain in favor of the app group, and two RCTs did not. Only in a non-RCT was there an increase in the disability score. In the application research conducted on mobile stores, we identified and rated 25 applications through MARS. The overall scores ranged from 1.93 to 3.92 for the IOS app and 1.73 to 4.25 for the Play Store app. The findings suggest that few apps meet satisfying quality, content, and functionality criteria for LBP self-management.

Self-acknowledged limitations in exercise therapy trials for low back pain

RATIONALE

Despite the widespread recommendation to engage in therapeutic exercise for the treatment of low back pain (LBP), there is conflicting evidence regarding clinical outcomes and effectiveness. Poor methodological quality may be to blame for reducing the overall strength of evidence for this intervention, yet little is known about the difficulties researchers encounter when designing and implementing their study methods.

AIMS AND OBJECTIVES

The aim of this study was to characterize the extent and type of self-acknowledged limitations (SALs) in exercise therapy trials for LBP to gain a better understanding of challenges encountered when conducting this research.

METHODS

This is a methodological review of clinical trials in which SALs were extracted, categorized by theme and subcategorized within each theme. Counts and prevalence rates were tabulated for the number of SALs in each category and subcategory.

RESULTS

There were 914 SALs among the 312 included trials, with a mean of 2.93 (95% confidence interval [CI], 2.77-3.09) per trial. Analysis of the data resulted in the development of 13 distinct categories of limitations, among which were 37 subcategories. The top three categories pertained to statistical power (14.3% of total SALs), study length and/or follow-up (14.3%) and inclusion criteria (14.2%). The top three subcategories were lack of long-term follow-up (13.8% of total SALs), inadequate sample size (13.3%) and inclusion of specific populations (12.3%).

CONCLUSION

Statistical power, study length and/or follow-up, and inclusion criteria were the three most commonly reported categories of SALs in exercise trials for LBP. Lack of long-term follow-up, inadequate sample size and inclusion of specific populations were the most common subcategories. Research protocols recognizing and avoiding these limitations will enhance the overall quality of evidence of exercise therapy trials for LBP.

Orthopaedic Manual Physical Therapy: A Modern Definition and Description

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis

BACKGROUND

Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm.

OBJECTIVE

To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP).

DESIGN

Retrospective cohort study using 2016-2019 Medicare data.

PARTICIPANTS

Fee-for-service Medicare beneficiaries with a new episode of aLBP.

MAIN MEASURES

The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date.

KEY RESULTS

We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed.

CONCLUSIONS

Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.

Research Priorities in the Mechanical Diagnosis and Therapy Among Diploma Therapists: An International Delphi Study

Introduction Mechanical diagnosis and therapy (MDT) is the most researched approach in musculoskeletal physical therapy and involves classifying patients into sub-groups based on their response to loading strategies. MDT diploma therapists (Dip-MDTs) fully recognize the value of MDT in musculoskeletal physical therapy. MDT is updating its system based on the latest research, but the system has not yet been fully established. Therefore, more research is required to increase the comprehensibility of the system. Thus, we aimed to identify future research priorities of MDT. Methods We conducted a modified Delphi study with three rounds. The Research Advisory Committee (RAC) members (n=7) of the McKenzie Institute International were invited to participate in the initial idea generation round. In the subsequent two consensus rounds, Dip-MDTs (n=299) were asked to indicate their level of agreement with the results of the idea generation round using a five-point Likert scale. The criteria for consensus were mean score ≥4.0, coefficient of variation ≤30%, percent agreement ≥75%, and quartile deviation ≤1. A post-hoc analysis of the consensus was conducted when the number of participants from a certain country exceeded one-third of the total number of participants. Results The participation rates for each round were 57.1%, 52.2%, and 49.8%. The USA accounted for 43.6% and 44.3% of all participants at the two consensus rounds, respectively. Finally, nine items reached consensus in the second consensus round. After the post-hoc analysis, eight items reached consensus: (1) cost-effectiveness, (2) cervical and thoracic spine, (3) extremity classifications, (4) filtered randomized controlled trials (RCTs), (5) spinal source classification, (6) centralization and directional preferences, (7) predictive factors for recurrence, and (8) patient education. Conclusion In this study, we identified the research priorities of MDT that would enhance the completion of the MDT system.

Demographic and clinical characteristics associated with failure of physical therapy in chronic low back pain: a secondary analysis from a randomized controlled trial

BACKGROUND

The effect of physical therapy on pain and disability alleviation in patients with chronic low back pain (cLBP) has been demonstrated, but the risk factors for treatment failure remain unknown.

AIM

To explore the associations of baseline demographic and clinical characteristics with treatment failure after physical therapy intervention for cLBP.

DESIGN

A secondary analysis of a single-blind randomized clinical trial.

SETTING

A rehabilitation hospital.

POPULATION

A total of 98 patients with cLBP completed the 12-month measurement.

METHODS

Patients were randomly grouped into 3-month therapeutic aquatic exercise or physical therapy modalities. The primary outcome was treatment failure, which was defined as a decrease in the numeric rating scale to less than 2.0 points at 12-month follow-up. Associations between baseline demographic and clinical characteristics with risk of treatment failure were assessed by logistic regressions.

RESULTS

The pain intensity in the failure cases was alleviated after 3-month intervention but continuously increased at 6- and 12-month follow-up (P<0.05). Old age was significantly associated with an increased risk of treatment failure (adjusted OR 3.26, 95% CI 1.11-9.60). Compared with those receiving physical therapy modalities, the patients receiving therapeutic aquatic exercise had less risk of treatment failure (adjusted OR 0.19, 95% CI 0.08-0.47), and age (P=0.022) was a modifier for this association.

CONCLUSIONS

Compared with younger ones, older patients with cLBP had a higher risk of treatment failure after physical therapy and gained a stronger benefit of long-term pain alleviation from therapeutic aquatic exercise.

CLINICAL REHABILITATION IMPACT

Therapeutic aquatic exercise is an effective therapy for cLBP and more helpful for preventing treatment failure than physical therapy modalities, especially for older patients.

Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus

OBJECTIVE

To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions.

DATA SOURCES

A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years.

REVIEW METHODS

Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts.

RESULTS

Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain.

CONCLUSIONS

The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5-10 years.

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists

INTRODUCTION

An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

METHOD

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

RESULTS

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined.

CONCLUSION

Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Clinically assessed lumbopelvic sensorimotor control tests in low back pain: are they actually valid? A systematic review according to COSMIN guidelines

BACKGROUND

Impairments in lumbopelvic sensorimotor control (SMC) are thought to be one of the underlying mechanisms for the recurrence and persistence of low back pain (LBP). As such, lumbopelvic SMC tests are frequently included in the clinical examination of patients with LBP.

OBJECTIVE

To evaluate convergent and known-groups validity of clinically assessed lumbopelvic SMC tests in patients with LBP according to COSMIN guidelines.

DESIGN

Systematic review METHODS: Five electronic databases were searched until December 2023. Studies examining convergent or known-groups validity of lumbopelvic SMC tests assessed via inspection or palpation in patients with LBP were included. Known-groups validity had to be assessed between patients with LBP and pain-free persons. Two independent researchers appraised risk of bias and quality of evidence (QoE) using the COSMIN Risk of Bias checklist and modified GRADE approach, respectively. Results for known-groups validity were reported separately for single tests and test-clusters.

RESULTS

Twelve studies (946 participants) were included. Three studies investigated convergent validity of three single tests. Regarding known-groups validity, six studies evaluated six single tests and four studies investigated two test-clusters. For only one test, both convergent and known-groups were assessed. The QoE for tests showing sufficient convergent or known-groups validity was (very) low, whereas QoE was moderate for single tests or test-clusters with insufficient known-groups validity.

CONCLUSION

All clinically assessed lumbopelvic SMC tests with sufficient convergent or known-groups validity had (very) low QoE. Therefore, test outcomes should be interpreted cautiously and strong reliance on these outcomes for clinical decision-making can currently not be recommended.

Finite Element Analysis of Stress Distribution and Range of Motion in Discogenic Back Pain

OBJECTIVE

Precise knowledge regarding the mechanical stress applied to the intervertebral disc following each individual spine motion enables physicians and patients to understand how people with discogenic back pain should be guided in their exercises and which spine motions to specifically avoid. We created an intervertebral disc degeneration model and conducted a finite element (FE) analysis of loaded stresses following each spinal posture or motion.

METHODS

A 3-dimensional FE model of intervertebral disc degeneration at L4-5 was constructed. The intervertebral disc degeneration model was created according to the modified Dallas discogram scale. The von Mises stress and range of motion (ROM) regarding the intervertebral discs and the endplates were analyzed.

RESULTS

We observed that mechanical stresses loaded onto the intervertebral discs were similar during flexion, extension, and lateral bending, which were greater than those occurring during torsion. Based on the comparison among the grades divided by the modified Dallas discogram scale, the mechanical stress during extension was greater in grades 3-5 than it was during the others. During extension, the mechanical stress loaded onto the intervertebral disc and endplate was greatest in the posterior portion. Mechanical stresses loaded onto the intervertebral disc were greater in grades 3-5 compared to those in grades 0-2.

CONCLUSION

Our findings suggest that it might be beneficial for patients experiencing discogenic back pain to maintain a neutral posture in their lumbar spine when engaging in daily activities and exercises, especially those suffering from significant intravertebral disc degeneration.

Precision Rehabilitation After Neurostimulation Implantation for Multifidus Dysfunction in Nociceptive Mechanical Chronic Low Back Pain

Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.

Efficacy of Laser Acupuncture for Treatment of Chronic Low Back Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To summarize and systematically analyze the efficacy of laser acupuncture (LA) interventions in reducing pain scores in patients suffering from chronic low back pain (LBP).

METHODS

PubMed, EMBASE, and Scopus databases were searched for randomized controlled trials, published in peer-reviewed journals, and reporting LA interventions in patients with chronic LBP. All included studies had a comparison group of patients, receiving placebo treatment, sham intervention, conventional therapy, or no treatment. The outcome of interest was the pain intensity score. Pooled effect estimates were calculated using random-effects models and reported as weighted mean difference (WMD) with 95% confidence intervals (CI).

RESULTS

A total of 20 studies were included. Compared to the control group, patients who underwent LA experienced a significant reduction in reported pain scores immediately after completing the treatment (WMD -1.14, 95% CI: -1.68 to -0.61). High dose of LA was associated with a more significant decrease in the pain scores (WMD -1.40, 95% CI: -1.94 to -0.85; N = 15, I2 = 81.0%). However, reported pain scores of patients who received LA were statistically similar to those of the control group at short-term (4-8 weeks after the treatment) and long-term (12 months) follow-ups.

CONCLUSIONS

In patients with chronic LBP, LA may help in alleviating pain immediately after the treatment. However, this effect does not appear to be sustained on later follow-up assessments. Consequently, patients should be informed about the potential limitations of the treatment in providing lasting pain relief.

Exploring the immediate and short-term effect of lumbar spinal manipulation on pressure pain threshold: a randomized controlled trial of healthy participants

BACKGROUND

Lumbar spinal manipulative therapy (SMT) is a common intervention used to treat low back pain (LBP); however, the exact neurophysiological mechanisms of SMT reducing pain measured through pain pressure threshold (PPT) have not been fully explored beyond an immediate timeframe (e.g., immediately or five-minutes following) referencing a control group. Therefore, the purpose of this study was to investigate the neurophysiological effects of lumbar SMT compared to deactivated ultrasound using PPT immediately following and 30-minutes following SMT.

METHODS

A longitudinal, randomized controlled trial design was conducted between September to October 2023. Fifty-five participants were randomized into a control group of deactivated ultrasound (n = 29) or treatment group of right sidelying lumbar SMT (n = 26). PPT, recorded at the right posterior superior iliac spine (PSIS), was documented for each participant in each group prior to intervention, immediately, and 30-minutes after. A repeated measures ANOVA, with a post-hoc Bonferroni adjustment, was used to assess within-group and between-group differences in PPT. The significance level was set at a < 0.05 a priori.

RESULTS

Statistically significant differences were found between the deactivated ultrasound and lumbar SMT groups immediately (p = .05) and 30-minutes (p = .02) following intervention. A significant difference in the lumbar SMT group was identified from baseline to immediately following (p < .001) and 30-minutes following (p < .001), but no differences between immediately following and 30-minutes following intervention (p = .10). The deactivated ultrasound group demonstrated a difference between baseline and immediately after intervention with a reduced PPT (p = .003), but no significant difference was found from baseline to 30-minutes (p = .11) or immediately after intervention to 30-minutes (p = 1.0).

CONCLUSION

A right sidelying lumbar manipulation increased PPT at the right PSIS immediately after that lasted to 30-minutes when compared to a deactivated ultrasound control group. Future studies should further explore beyond the immediate and short-term neurophysiological effects of lumbar SMT to validate these findings.

TRIAL REGISTRATION

This study was retrospectively registered on 4 December 2023 in ClinicalTrials (database registration number NCT06156605).

On-Site Physiotherapy in Emergency Department Patients Presenting with Nonspecific Low Back Pain: A Randomized Controlled Trial

Background: There is a high incidence of nonspecific Low Back Pain (LBP) in patients visiting Emergency Departments (EDs), but there is a lack of knowledge regarding emergency physiotherapy for LBP. The effect of on-site physiotherapy in these patients was therefore never demonstrated. We assessed short-term outcomes, feasibility and patient satisfaction with physiotherapy in ED patients presenting with nonspecific LBP. Methods: A block-randomized, controlled, open-label trial with a follow-up of 42 days. Patients aged 18 years or older presenting to an ED with nonspecific LBP were prospectively enrolled. Both groups received the same booklet with written information on LBP management and exercises. Patients in the intervention group were given additional instructions by a certified physiotherapist. Results: We included 86 patients in the primary analysis. The median age was 40, and 40.7% were female. At day 7, the median Oswestry Disability Index (ODI) was 2 points lower in the intervention group compared to the control group, which was not statistically significant. There was no between-group difference in pain at day 7. Patients who received physiotherapy felt significantly more confident with the exercises they were taught (p = 0.004, effect size = 0.3 [95% CI 0.1 to 0.5]). Conclusions: On-site physiotherapy in ED patients presenting with nonspecific low back pain is associated with higher patient satisfaction, compared to standard of care. The effect of physiotherapy was small, with only minimal improvement in disability, but without a reduction in pain. Despite the very small effect size, physiotherapeutic interventions should be investigated in larger cohorts with an extended intervention including patient education, exercises, and other physiotherapeutic modalities.

Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis

Chronic low back pain (cLBP) is a major cause of disability and healthcare expenditure worldwide. Its prevalence is increasing globally from somatic and psychosocial factors. While non-pharmacological management, and in particular physiotherapy, has been recommended as a first-line treatment for cLBP, it is not clear what type of physiotherapeutic approach is the most effective in terms of pain reduction and function improvement. This analysis is rendered more difficult by the vast number of available therapies and a lack of a widely accepted classification that can effectively highlight the differences in the outcomes of different management options. This study was conducted according to the PRISMA guidelines. In January 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All the randomised controlled trials (RCTs) which compared the efficacy of physiotherapy programs in patients with cLBP were accessed. Studies reporting on non-specific or mechanical cLPB were included. Data concerning the Visual Analogic Scale (VAS) or numeric rating scale (NRS), Roland Morris Disability Questionnaire (RMQ) and Oswestry Disability Index (ODI). Data from 12,773 patients were collected. The mean symptom duration was 61.2 ± 51.0 months and the mean follow-up was 4.3 ± 5.9 months. The mean age was 44.5 ± 9.4 years. The mean BMI was 25.8 ± 2.9 kg/m2. The Adapted Physical Exercise group evidenced the lowest pain score, followed by Multidisciplinary and Adapted Training Exercise/Complementary Medicine. The Adapted Physical Exercise group evidenced the lowest RMQ score followed by Therapeutic Exercises and Multidisciplinary. The Multidisciplinary group evidenced the lowest ODI score, followed by Adapted Physical Exercise and Physical Agent modalities. Within the considered physiotherapeutic and non-conventional approaches to manage nonspecific and/or mechanic cLBP, adapted physical exercise, physical agent modalities, and a multidisciplinary approach might represent the most effective strategy to reduce pain and disability.

Synergistic neuromodulation therapy for persistent spinal pain: a proof-of-concept trial on the use of spinal cord and dorsal root ganglion stimulation

PURPOSE

Persistent Spinal Pain Syndrome type 2 (PSPS-T2) poses a significant clinical challenge, demanding innovative therapeutic interventions. The integration of Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion Stimulation (DRG-S) is emerging as a potent synergistic strategy for comprehensive pain management. This single patient-blind proof of concept (POC) trial explores the efficacy and synergistic potential of combined SCS and DRG-S in a patient with refractory PSPS-T2.

METHODS

A 45-year-old male with intractable PSPS-T2 underwent a unique, methodically structured study, involving three treatment phases: Phase A with SCS alone, Phase B with DRG-S alone, and Phase C The patient, blinded to the treatment modalities, provided pain assessments using the Visual Analogue Scale (VAS) and Douleur Neuropathique 4 Questions (DN4) conducted by clinical investigators at each phase. Baseline pain scores were ten and nine, respectively.

RESULTS

Distinct responses were noted across the phases. Phase A demonstrated moderate pain relief, while Phase B offered further pain intensity reduction. However, Phase C, combining both strategies, yielded the most significant improvement, remarkably enhancing the patient's quality of life and functional capacity.

CONCLUSION

This POC trial underscores the synergistic potential of SCS and DRG-S in managing complex cases of PSPS-T2, suggesting a paradigm shift towards integrated neuromodulation strategies for enhanced pain control. The development of dual intent implantable pulse generators (IPGs) capable of offering combination therapy simultaneously might be effective for pain management in select cases. The significant pain reduction and functional improvement observed advocate for further research in dual neuromodulation therapies.

TRIAL REGISTRATION NUMBER

IRB 20190536.

Quality of Life in Patients with Chronic Low Back Pain and Differences by Sex: A Longitudinal Study

BACKGROUND

The experience of chronic low back pain has a significant impact on the quality of life of affected people, resulting in difficulties in performing basic activities of daily living.

AIM

To study the perceived quality of life of people affected by chronic low back pain and the associated factors by sex.

METHODS

A prospective, longitudinal and observational design was used.

RESULTS

A total of 129 people (58.1% women) with chronic low back pain were studied. The mean pain intensity scores were of moderate severity (6.42 points), with a modest improvement at follow-up (6.17 points). Epidural nerve blocks were the most effective therapeutic intervention in reducing the intensity of pain. Participants described a negative perception of their health with regard to quality of life, with low scores for the two constructs both at baseline (health index, 0.444; perception of health, 38.76 points) and at follow-up (health index, 0.447; perception of health, 40.43 points). Participants had severe functional limitation scores (50.79 points). The results were significantly better among men. There was an inverse relationship between the average pain intensity (β = -0.304; p < 0.001), functional limitation (β = -0.466; p < 0.001) and mental health (β = -0.565; p < 0.001) and quality of life.

CONCLUSIONS

The chronification of low back pain complicates people's biopsychosocial adaptation to life. There is a longitudinal inverse association between pain and functional limitation and health-related quality of life.

Immediate effect of extracorporeal shockwave therapy in patients with chronic non-specific low back pain: A randomised placebo-controlled triple-blind trial

OBJECTIVE

To compare the immediate effects of shockwave therapy using two different tips in patients with chronic non-specific low back pain.

DESIGN

Randomised placebo-controlled study with three intervention groups.

SETTING

The patients recruited for this study were sent for physiotherapy treatment at primary care between May and July 2022.

PARTICIPANTS

Eighty-one patients with chronic non-specific low back pain aged 18-80 years with pain for ≥3 months and pain intensity ≥3 were randomly recruited for the study.

INTERVENTION

The patients received a single intervention of radial shockwave therapy with 2000 discharges at 100 mJ energy and 5 Hz frequency using concave or convex tips or placebo treatment.

MAIN MEASURES

The primary outcome was pain intensity immediately post-intervention. The secondary outcomes were pressure pain threshold, temporal summation of pain, and functional performance. Data were collected at baseline and post-intervention.

RESULTS

The post-intervention pain intensity in the concave tip group is an average of two points lower (95% CI = -3.6, -0.4; p < 0.01) than that in the placebo group. The post-intervention pressure pain threshold for the concave tip group was an average of 62.8 kPa higher (95% CI = 0.4, 125.1; p < 0.05) than for the convex tip group and 76.4 kPa higher (95% CI = 14, 138.7; p < 0.01) than in the placebo group.

CONCLUSION

The concave tip shockwave therapy is effective in reducing pain and local hyperalgesia in patients with chronic non-specific low back pain.

Repetitive Transcranial Magnetic Stimulation Combined with Sling Exercise Modulates the Motor Cortex in Patients with Chronic Low Back Pain

The study aims to explore the effects of combining repetitive transcranial magnetic stimulation (rTMS) with sling exercise (SE) intervention in patients with chronic low back pain (CLBP). This approach aims to directly stimulate brain circuits and indirectly activate trunk muscles to influence motor cortex plasticity. However, the impact of this combined intervention on motor cortex organization and clinical symptom improvement is still unclear, as well as whether it is more effective than either intervention alone. To investigate this, patients with CLBP were randomly assigned to three groups: SE/rTMS, rTMS alone, and SE alone. Motor cortical organization, numerical pain rating scale (NPRS), Oswestry Disability Index (ODI), and postural balance stability were measured before and after a 2-week intervention. The results showed statistically significant differences in the representative location of multifidus on the left hemispheres, as well as in NPRS and ODI scores, in the combined SE/rTMS group after the intervention. When compared to the other two groups, the combined SE/rTMS group demonstrated significantly different motor cortical organization, sway area, and path range from the rTMS alone group, but not from the SE alone group. These findings highlight the potential benefits of a combined SE/rTMS intervention in terms of clinical outcomes and neuroadaptive changes compared to rTMS alone. However, there was no significant difference between the combined intervention and SE alone. Therefore, our research does not support the use of rTMS as a standalone treatment for CLBP. Our study contributed to optimizing treatment strategies for individuals suffering from CLBP.

The influence of low back pain-related attitudes and beliefs on the clinical decision making of physical therapists

BACKGROUND

The LBP-related attitudes and beliefs of clinicians may impact the experience of patients by influencing clinician decision-making and by shaping the attitudes, beliefs, and actions of patients. The purpose of this study was to identify the specific LBP-related attitudes and beliefs of US-based physical therapists and determine if those beliefs correlate with clinical decision-making.

METHODS

An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain and Impairment Relationship Scale for Physiotherapists (PABS-PT). The survey also included 2 patient vignettes that collected information about clinical decision-making.

RESULTS

Complete survey responses were recorded from 420 physical therapists. Eleven of the 27 attitude and beliefs questions were answered in a more biomedically oriented way by at least 20% of respondents. Physical therapist low back pain-related attitudes and beliefs were associated with activity and management strategies for both vignettes in the expected direction. Higher scores on HC-PAIRS and PABS-BM were associated with more restrictive work and activity recommendations, lower-intensity exercise choices, biomechanical rationale for manual therapy and motor control exercises, pathoanatomical-focused education, and use of modalities.

CONCLUSION

Some physical therapists hold biomedically oriented beliefs about the connection between pain and physical activity. Clinician beliefs were associated with activity and work recommendations, and treatment choices. Physical therapists with more biomedically oriented beliefs were more likely to limit physical activity and work, and less likely to incorporate psychologically informed interventions.

Application of the Staged Approach for Rehabilitation Classification System and Associated Improvements in Patient-Reported Outcomes Following Rehabilitation for Shoulder Pain

OBJECTIVE

The Staged Approach for Rehabilitation Classification for the Shoulder (STAR-Shoulder) has been proposed as a model to guide management and improve outcomes for patients with shoulder pain; however, the effect of its utilization on patient outcomes has not been established. Therefore, the primary purpose of this study was to determine whether patient outcomes were improved if care was matched to the STAR-Shoulder system compared with unmatched care.

METHODS

Collected and reviewed demographic, examination, and intervention data for all patients receiving physical therapist treatment for shoulder pain during a 1-year period within a single health care system. Outcome variables included the numeric pain rating scale, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the number of visits. Clinical records from patients receiving care at the discretion of the therapist were systematically audited to determine whether care provided was considered matched or unmatched.

RESULTS

A total of 692 patient records were examined. The interrater reliability of classifying care as matched or unmatched was substantial (κ = 0.6; 95% CI = 0.4 to 0.9), with 82% agreement. Changes in patient outcome scores were significantly better for those patients whose care matched the STAR-Shoulder system for pain changes (mean difference = -1.2; 95% CI = 0.8 to 1.6; effect size [d] = 0.5) and QuickDASH score (mean difference = 12.7; 95% CI = 9.9 to 15.5; d = 0.7). No difference was noted for number of visits.

CONCLUSION

The STAR-Shoulder system appears to be a meaningful way to classify patients and guide intervention to improve patient outcomes.

IMPACT

Application of the STAR-Shoulder system to help align physical therapist interventions more closely with tissue irritability and physical impairments appears to improve patient outcomes. These findings support this model as a promising approach to advance evidence-based practice for shoulder pain.

The Best Exercise Modality and Dose for Reducing Pain in Adults With Low Back Pain: A Systematic Review With Model-Based Bayesian Network Meta-analysis

OBJECTIVE: To quantify the dose-response relationship between overall and specific exercise modalities and pain, in patients with nonspecific chronic low back pain (LBP). DESIGN: Systematic review with Bayesian network meta-analysis. LITERATURE SEARCH: We searched the Medline, Embase, Web of Science, Cochrane Library, Scopus, and SPORTDiscus databases from inception to June 2023. STUDY SELECTION CRITERIA: We included randomized controlled trials of exercise interventions in adults with nonspecific chronic LBP and at least 1 pain outcome reported at the main trial end point. DATA SYNTHESIS: A random-effects network meta-analysis was conducted. We assessed risk of bias using the Cochrane Risk of Bias Tool 2.0, and used the GRADE approach to judge the certainty of evidence for each outcome. RESULTS: Eighty-two trials were included (n = 5033 participants). We found a nonlinear dose-response relationship between total exercise and pain in patients with nonspecific chronic LBP. The maximum significant response was observed at 920 MET minutes (standardized mean difference = -1.74; 95% credible intervals: -2.43, -1.04). The minimal clinically important difference for achieving meaningful pain improvement was 520 MET minutes per week. The dose to achieve minimal clinically important difference varied by type of exercise; Pilates was the most effective. The certainty of the evidence was very low to moderate for all outcomes. CONCLUSION: The dose-response relationship of different exercise modalities to improve pain in patients with nonspecific chronic LBP had a U-shaped trajectory and low- to moderate-certainty evidence. The clinical effect was most pronounced with Pilates exercise. J Orthop Sports Phys Ther 2024;54(5):1-13. Epub 8 March 2024. doi:10.2519/jospt.2024.12153.

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

PURPOSE

To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care.

METHODS

We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points).

RESULTS

We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC.

CONCLUSIONS

Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

Recent clinical practice guidelines for the management of low back pain: a global comparison

BACKGROUND

Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world.

METHODS

MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture.

CONCLUSIONS

Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.

Manual therapy and exercise effects on inflammatory cytokines: a narrative overview

Background

Matching disease and treatment mechanisms is a goal of the Precision Medicine Initiative. Pro- and anti-inflammatory cytokines (e.g., Tumor Necrosis Factor-alpha, Transforming Growth Factor-beta, and Interleukin-2, 10, and 12) have gained a significant amount of interest in their potential role in persistent pain for musculoskeletal (MSK) conditions. Manual therapy (MT) and exercise are two guideline-recommended approaches for treating MSK conditions. The objective of this narrative overview was to investigate of the effects of MT and exercise on pro- and anti-inflammatory cytokines and determine the factors that lead to variability in results.

Methods

Two reviewers evaluated the direction and variabilities of MT and exercise literature. A red, yellow, and green light scoring system was used to define consistencies.

Results

Consistencies in responses were seen with acute and chronic exercise and both pro- and anti-inflammatory cytokines. Chronic exercise is associated with a consistent shift towards a more anti-inflammatory cytokine profile (Transforming Growth Factor-beta, and Interleukin-2 and 13, whereas acute bouts of intense exercise can transiently increase pro-inflammatory cytokine levels. The influence of MT on cytokines was less commonly studied and yielded more variable results.

Conclusion

Variability in findings is likely related to the subject and their baseline condition or disease, when measurement occurs, and the exercise intensity, duration, and an individual's overall health and fitness.

The effectiveness of instrument-assisted soft tissue mobilization on range of motion: a meta-analysis

BACKGROUND

To evaluate the effectiveness of instrument-assisted soft tissue mobilization (IASTM) on range of motion (ROM).

METHODS

We performed a literature search of the PubMed, Embase, Web of Science, and Cochrane Library databases from inception to December 23, 2023. Randomized controlled trials that compared treatment groups receiving IASTM to controls or IASTM plus another treatment(s) to other treatment(s) among healthy individuals with or without ROM deficits, or patients with musculoskeletal disorders were included. The Cochrane risk of bias tool was used to assess the risk of bias.

RESULTS

Nine trials including 450 participants were included in the quantitative analysis. The IASTM was effective in improving ROM in degree in healthy individuals with ROM deficits and patients with musculoskeletal disorders (n=4) (MD = 4.94, 95% CI: 3.29 to 6.60), and in healthy individuals without ROM deficits (n=4) (MD = 2.32, 95% CI: 1.30 to 3.34), but failed to improve ROM in centimeter in healthy individuals with ROM deficits (n=1) (MD = 0.39, 95% CI: -1.34 to 2.11, p=0.66, I2 = 88%).

CONCLUSIONS

IASTM can improve ROM in degree in healthy individuals with or without ROM deficits, or in patients with musculoskeletal disorders (with very low to low certainty).

TRIAL REGISTRATION

The PROSPERO registration ID is CRD42023425200.

Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials

In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.

Lumbar Paravertebral Muscle Pain Management Using Kinesitherapy and Electrotherapeutic Modalities

BACKGROUND

Low back pain is considered a public health problem internationally. Low back pain is a cause of disability that occurs in adolescents and causes negative effects in adults as well. The work environment and physical and psychosocial factors can influence the occurrence and evolution of low back pain.

METHODS

The purpose of this paper is to highlight the physiological and functional changes in young adults with painful conditions of the lumbar spine, after using exercise therapy. The study was of the longitudinal type and was carried out over a period 6 months in an outpatient setting. The rehabilitation treatment included electrotherapeutic modalities and kinesitherapy.

RESULTS

The results obtained when evaluating each parameter, for all moments, show statistically significant values in both groups. The results obtained regarding the relationship between the therapeutic modalities specific to rehabilitation medicine and low back pain are consistent with those reported in studies.

CONCLUSIONS

Depending on the clinical-functional status of each patient, kinesitherapy can accelerate the heart rate and increase the blood pressure and oxygen saturation of the arterial blood, values that can later return to their initial levels, especially through training.

Comparison of the Electromyography Activity during Exercises with Stable and Unstable Surfaces: A Systematic Review and Meta-Analysis

The effect of electromyographic (EMG) activity on agonist muscles during exercises performed on stable and unstable surfaces remains uncertain. We aimed to review the literature regarding the comparison of the EMG activity of the agonist muscles of exercises performed on stable and unstable surfaces. Eighty-six studies that evaluated the EMG activity of 1783 individuals during exercises for the lower limbs, upper limbs, and core were included. The EMG activities of the pectoralis major (SMD = 0.28 [95% CI 0.09, 0.47]) and triceps brachii muscles (SMD = 0.45 [95% CI 0.25, 0.66]) were significantly increased when the unstable device was added to the exercise. Likewise, the EMG activity of all core muscles showed a significant increase with the unstable surface during the exercises, such as the rectus abdominis (SMD = 0.51 [95% CI 0.37, 0.66]), external oblique (SMD = 0.44 [95% CI 0.28, 0.61]), internal oblique (SMD = 1.04 [95% CI 0.02, 2.07]), erector spinae (SMD = 0.37 [95% CI 0.04, 0.71]), and lumbar multifidus (SMD = 0.35 [95% CI 0.08, 0.61]). However, the lower limb muscles did not show greater EMG activity during the exercise with unstable surfaces compared to the stable surface. In conclusion, unstable conditions increase the EMG activity of some upper limb and core muscles compared to a stable surface.

Exercise induced hypoalgesia during different intensities of a dynamic resistance exercise: A randomized controlled trial

INTRODUCTION

Exercise produces an immediate lessening of pain sensitivity (Exercise-Induced Hypoalgesia (EIH)) in healthy individuals at local and distant sites, possibly through a shared mechanism with conditioned pain modulation (CPM). Dynamic resistance exercise is a recommended type of exercise to reduce pain, yet limited research has examined the effects of intensity on EIH during this type of exercise. Therefore, the primary purpose of this study is to compare changes in PPT at a local and distant site during a leg extension exercise at a high intensity, a low intensity, or a quiet rest condition. A secondary purpose is to examine if CPM changes after each intervention. The final purpose is to examine if baseline pain sensitivity measures are correlated with response to each intervention.

METHODS

In a randomized controlled trial of 60 healthy participants, participants completed baseline pain sensitivity testing (heat pain threshold, temporal summation, a cold pressor test as measure of CPM) and were randomly assigned to complete a knee extension exercise at: 1) high intensity (75% of a 1 Repetition Maximum (RM), 2) low intensity (30% 1RM), or 3) Quiet Rest. PPT was measured between each set at a local (quadriceps) and distant (trapezius) site during the intervention. CPM was then repeated after the intervention. To test the first purpose of the study, a three-way ANOVA examined for time x site x intervention interaction effects. To examine for changes in CPM by group, a mixed-model ANOVA was performed. Finally, a Pearson Correlation examined the association between baseline pain sensitivity and response to each intervention.

RESULTS

Time x site x intervention interaction effects were not significant (F(5.3, 150.97) = 0.87, p = 0.51, partial eta2 = 0.03). CPM did not significantly change after the interventions (time x intervention F(1,38) = 0.81, p = 0.37, partial eta2 = 0.02. EIH effects at the quadriceps displayed a significant, positive moderate association with baseline HPT applied over the trapezius (r = 0.61, p<0.01) and TS (r = 0.46, p = 0.04).

DISCUSSION

In healthy participants, PPT and CPM did not significantly differ after a leg extension exercise performed at a high intensity, low intensity, or quiet rest condition. It is possible pre-intervention CPM testing with a noxious stimuli may have impaired inhibitory effects frequently observed during exercise but future research would need to examine this hypothesis.

Effects of transcutaneous electrical nerve stimulation on pain, function, and descending inhibition in people with non-specific chronic low-back pain: a study protocol for a randomized crossover trial

BACKGROUND

Low back pain (LBP) is a significant public health problem, is very prevalent, and is often characterized by the persistence of symptoms. Transcutaneous electrical nerve stimulation (TENS) may benefit people with chronic LBP because it can activate descending inhibitory pathways and inhibit central excitability. However, previous studies that have investigated the effects of TENS on pain in people with LBP have failed to use proper intensities of current, and the timing of the assessment of pain was not performed during the peak of the analgesic response or functional activities. Therefore, the present study aims to assess the effects of TENS on measures of pain, function, and descending inhibition using the maximal tolerable intensity of TENS in participants with LBP.

METHODS/DESIGN

This study will be a randomized crossover trial. The participants for this study will be recruited from various places, including the University of Hartford, physical therapy clinics, and local businesses in the Hartford area, as well as online websites geared towards clinical trial recruitment. A total of 34 participants will receive all three treatments: active TENS, placebo TENS, and no treatment control. The treatment order will be randomized using a website-based randomization tool. For active TENS, a modulating frequency of 2-125 Hz will be applied with a variable pulse duration and maximal tolerable intensity for 30 min. The TENS will be left on for post-treatment testing to assess the effects during its maximally effective period for a total of 50 to 60 min. Furthermore, the intensity may be turned down if muscle twitching is present to ensure blinding of the evaluator. For placebo TENS, the unit will deliver current for 45 s, ramping to 0 in the last 15 s. The primary outcome will be pain intensity at rest and with movement, determined using the numerical pain rating scale. The secondary outcomes will be pressure pain threshold, heat pain threshold, temporal summation of pain, conditioned pain modulation, sit-to-stand test, and repeated trunk flexion. The assessments will be performed immediately before and after treatment. Statistical analysis of the data obtained will consider a significance level of p < 0.05.

DISCUSSION

This study will provide evidence concerning the effects and mechanisms of TENS treatment in participants with chronic non-specific low back pain. The outcomes, including pain, function, and descending inhibition, will help us gain a greater understanding of how TENS can be used for these participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05812885. Registered on 24th May 2023.

The efficacy of silver needle therapy for treating low back pain: a protocol for meta-analysis of randomized controlled trials

Background

As population aging and unhealthy living habits may exacerbate the prevalence and burden of low back pain (LBP), effective treatment and improvement of patient quality of life are particularly critical. Silver needle therapy (SNT), having evolved from traditional acupuncture, involves placing silver needles into muscles, tendons, and fascia for treatment. However, it still lacks robust clinical evidence to substantiate its effectiveness. Therefore, it is necessary to conduct more emphasis on meta-analysis to evaluate the clinical efficacy of SNT for treating LBP.

Methods

We will search PubMed, Medline, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Databases up until December 2023 to identify randomized controlled trials of SNT treatment in adult patients with LBP. The primary outcome will be the intensity of pain after pain management. Secondary outcomes will include the Oswestry Disability Index, Japanese Orthopedic Association Back Pain Evaluation Questionnaire, requirement for analgesic drugs, and treatment-related adverse reactions. Two investigators conducted the literature search, selected studies that might meet the inclusion criteria based on the title and abstract, and extracted data from the eligible literature independently and will independently assess the risk of bias using the Revised Cochrane Risk-of-Bias (RoB2) tool. Multivariate analyses (including subgroup analysis, trial sequential analysis (TSA), sensitivity analysis, etc.) will be conducted to improve the quality of evidence.

Clinical trial registration

Registration: PROSPERO Registration Number: CRD42023466207, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023466207.

Evaluating and Characterizing the Scope of Care for Interventions Labeled as Manual Therapy in Low Back Pain Trials: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to evaluate and characterize the scope of care for low back pain that falls under the specific label of manual therapy.

METHODS

PubMed database, Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and SPORTDiscus were searched from journal inception through May 2022 for randomized controlled trials that investigated the treatment of low back pain using manual therapy. Terminology used to define manual therapy was extracted and categorized by using only the words included in the description of the intervention. An expert consultation phase was undertaken to gather feedback.

RESULTS

One hundred seventy-six trials met final inclusion criteria, and 169 unique terms labeled as manual therapy for the treatment of low back pain were found. The most frequent terms were mobilization (29.0%), manipulation (16.0%), and thrust (6.4%). Eight percent of trials did not define or specify what type of manual therapy was used in the study. After removing duplicates, 169 unique terms emerged within 18 categories.

CONCLUSIONS

Manual therapy intervention labels used in low back pain trials are highly variable. With such variation, the heterogeneity of the intervention in trials is likely large, and the likelihood that different trials are comparing the same interventions is low. Researchers should consider being more judicious with the use of the term manual therapy and provide greater detail in titles, methods, and supplementary appendices in order to improve clarity, clinical applicability, and usefulness of future research.

IMPACT

The ability to interpret and apply findings from manual therapy-related research for low back pain is challenging due to the heterogeneity of interventions under this umbrella term. A clear use of terminology and description of interventions by researchers will allow for improved understanding for the role of manual therapy in managing back pain.

How do non-specific back pain patients think about their adherence to physiotherapy, and what strategies do physiotherapists use to facilitate adherence? A focus group interview study

BACKGROUND

Long-term effectiveness of physiotherapy (PT) for low back pain (LBP) depends on the adherence of patients. Objectives: (1) Identify aspects associated with the adherence of patients with LBP to physiotherapy, and (2) identify factors to facilitate adherence of patients with LBP to PT.

METHOD

Focus group interviews were conducted with 10 patients with LBP (n = 10, 5 women) and 11 physiotherapists (5 women) from Germany and Switzerland, treating patients with LBP. Data analysis was based on structured content analysis. Deductive and inductive categories were identified and coded.

RESULTS

Patients with LBP requested more and effective home programs, long-term rehabilitation management, and individualized therapy to achieve a higher level of adherence. Physiotherapists requested more time for patient education. Communication, quality of the therapist-patient relationship, and individualized therapy were identified as essential factors by both representatives.

CONCLUSION

Patients and physiotherapists identified aspects contributing to adherence. These may guide the development of multidimensional measurement tools for adherence. In addition, this information can be used to develop PT approaches to facilitate the level of adherence.

Financial impact associated with implementation of the low back pain clinical practice guideline in outpatient physical therapist practice at a large academic medical center

INTRODUCTION

Low back pain (LBP) is the top health condition requiring rehabilitation in the United States. The financial burden of managing LBP is also amongst the highest in the United States. Clinical practice guidelines (CPGs) provide management recommendations and have the potential to lower health costs. Limited evidence exists on the impact of CPG implementation on downstream medical costs.

OBJECTIVE

To examine the impact of CPG implementation in physical therapist (PT) practice on direct and downstream costs for patients with LBP.

METHODS

A retrospective observational study examined billing data from 270 patients with LBP who were treated at multiple sites within one large academic medical center by PTs who participated in a multifaceted CPG implementation program. Costs were analyzed for direct PT services, downstream medical services, and PT utilization from September 2017 to March 2018 (pre-implementation group) and compared with costs from June 2018 to December 2018 (post-implementation group).

RESULTS

Direct PT costs were significantly lower post-implementation than pre-implementation mean: $2,863 USD (SD: $1,968) vs. $3,459 USD (SD: $2,838), p = .05, 95% CI [11, 1182]. All downstream costs were lower post-implementation with statistically significant lower costs found in downstream imaging: p = .04, 95% CI [32, 1,905]; pharmacy: p = .03, 95% CI [70, 1,217]; surgery: p = .03, 95% CI [446, 9,152], and "other": p = .02, 95% CI [627, 7,920].

CONCLUSION

Implementing the LBP CPG in outpatient PT practice can have a positive impact on lowering downstream costs and the potential to increase the value of PT services.

Advanced practice physiotherapy surgical triage and management of adults with spinal disorders referred to specialized spine medical care: a retrospective observational study

INTRODUCTION

In this novel advanced practice physiotherapy (APP) model of care, advanced practice physiotherapists (APPTs) assess, triage, and manage adults with spinal disorders to alleviate the growing demands in specialized spine medical care.

OBJECTIVES

To describe this APP model of care, to assess change in disability 3 months after rehabilitation care and to assess surgical triage and diagnostic concordance between APPTs and spine surgeons.

METHODS

In this retrospective observational study, consecutive patients who completed the 3-month follow-up data were analyzed. Sociodemographic, clinical characteristics, and self-reported disabilities including the Oswestry Disability Index (ODI) and Neck Disability Index (NDI) at baseline and 3 months were extracted. Paired t-tests were used to assess changes in disability. Surgical triage and diagnostic concordance between APPTs and surgeons were measured with raw agreement, Cohen's Kappa, and PABAK.

RESULTS

In this model, trained APPTs triaged surgical candidates and provided rehabilitation care including education and exercises to patients with spinal disorders. The APPTs referred only 18/46 participants to spine surgeons. Surgical triage and diagnostic concordance were high with raw agreement of 94% and 89%. At the 3-month follow-up, significant improvements in disability were observed among nonsurgical candidates with back (mean difference (MD): -13.0/100 [95%CI: -19.8 to -6.3], n = 23) or neck disorders (MD: -16.0/100 [95%CI: -29.6 to -2.4], n = 5), but not among surgical candidates referred by APPTs to spine surgeons.

CONCLUSION

In this limited sample, adults with spinal disorders that were initially referred to a spine surgeon by family physicians were effectively assessed, triaged, and managed by an APPT.

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

Effects of Manual Therapy Plus Pain Neuroscience Education with Integrated Motivational Interviewing in Individuals with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial Study

Background and Objectives: Chronic non-specific low back pain (CNLBP) persists beyond 12 weeks. Manual therapy recommended for CNLBP demonstrates short-term efficacy. Pain Neuroscience Education (PNE) teaches patients to modify pain perception through explanations, metaphors, and examples, targeting brain re-education. Motivational Interviewing (MI) enhances motivation for behavioral change, steering patients away from ambivalence and uncertainty. These approaches collectively address the multifaceted nature of CNLBP for effective management. The aim of this study was to investigate a manual therapy intervention combined with PNE with MI on pain, pressure pain threshold (PPT), disability, kinesiophobia, catastrophizing, and low back functional ability in individuals experiencing CNLBP. Materials and Methods: Sixty adults with CNLBP were randomly divided into three equal groups (each n = 20). The first group received manual therapy and PNE with integrated MI (combined therapy group), the second group underwent only manual therapy (manual therapy group), and the third group followed a general exercise program at home (control group). Pain in the last 24 h was assessed using the Numeric Pain Rating Scale (NPRS), functional ability with the Roland-Morris Disability Questionnaire (RMDQ), PPT in the lumbar region through pressure algometry, kinesiophobia with the Tampa Scale for Kinesiophobia (TSK), catastrophizing with the Pain Catastrophizing Scale (PCS), and performance using the Back Performance Scale (BPS) at baseline, in the fourth week, and six months post-intervention. Results: Statistically significant differences between the intervention groups and the control group were found in both the fourth-week measurement and the six-month follow-up, as evident in the NPRS and RMDQ scores, as well as in the total values of tested PPTs (p < 0.05). Differences were also observed between the two intervention groups, with a statistically greater improvement in the combined therapy group at both time points (fourth week and six-month follow-up) (p < 0.05). Regarding the TSK and PCS scores in the fourth week, statistically significant differences were observed between the two intervention groups compared to the control group, as well as between the two intervention groups (p < 0.05). However, in the six-month follow-up, statistically significant differences were found only between the combined therapy group and the other two groups, with the combined therapy group showing significant improvements (p < 0.05). In relation to BPS, both intervention groups exhibited statistically significant differences compared to the control group in the fourth week, without any significant differences between the two intervention groups. However, in the six-month follow-up, significant differences were noted between the combined therapy group and the other two groups (p < 0.05), with combined therapy demonstrating greater improvement. Conclusions: The addition of PNE with integrated MI enhanced the positive effects of a manual therapy intervention in all outcome measures. The combination of manual therapy plus PNE with integrated MI appeared to provide greater improvements compared to the isolated application of manual therapy, and these improvements also lasted longer. These short- and long-term positive effects are likely attributed to the combination of PNE with integrated MI, which contributed to increasing the effectiveness of the treatment. Further studies are required to investigate the optimum dosage of manual therapy and PNE with integrated MI in individuals with CNLBP.