Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process

OBJECTIVE

The purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination.

METHODS

A modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale.

RESULTS

Consensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included.

CONCLUSION

An expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.

Experiences of community-dwelling older adults with chronic low back pain in Hong Kong and Switzerland - A qualitative study

Introduction

The prevalence of chronic low back pain (LBP) increases with age and older adults are more vulnerable to develop chronic LBP. A recent Swiss study has shown that 78% of community-dwelling older adults aged ≥65 years experienced chronic LBP. Similarly, a study in Hong Kong found that approximately 30% of people aged above 60 years experienced chronic LBP. The aim of this collaborative research project was to illuminate older adults' experiences of living with chronic LBP and its implication on older adults' daily life in Western and Eastern cultures.

Methods

Twenty-five older people experiencing chronic LBP living in Switzerland or Hong Kong were recruited through health professionals or community centres. Using semi-structured interviews, participants shared their experiences regarding chronic LBP and its implications on their daily life. The interviews were recorded and transcribed "ad verbatim" in the original language. An inductive thematic analysis was used, using a qualitative data analysis software program (NVivo) and a shared code book in English. The Swiss and Hong Kong research teams engaged in collaborative analysis until a consensus was established, taking into consideration of cultural specificities. Ethical approval was obtained from the local ethic committees in both regions.

Results

Themes were related to negative perceptions/experiences: (1) interferences of daily function; (2) pessimistic attitudes toward their conditions/prognosis; and (3) self-perceived burden related to families. Conversely, four themes revealed attributes to social roles: (1) maintaining their roles in families; (2) experiencing supports from family and friends; (3) being content despite LBP; and (4) enjoying social activities. Cultural differences between Switzerland and Hong Kong were related to social circles and offers from the healthcare system, influencing individual experiences and perceptions.

Discussion

Although chronic LBP may negatively impact older adults, individual approaches as well as social and health system supports influence older adults' attitude toward their pain and self-management strategies. Developing effective and culturally sensitive interventions for an elderly population with chronic LBP can be challenging but essential for the development of innovative healthcare services tailored to the population's needs. The methodological approach used for this research project establishes the framework for developing and evaluating complex interventions.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study

BACKGROUND

Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.

OBJECTIVE

The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.

METHODS

Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.

RESULTS

From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95% CI -20.32 to -13.42 in cluster 1 to -20.10, 95% CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).

CONCLUSIONS

A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Well-described exercises for chronic low back pain in Life Science Literature: A systematic review

BACKGROUND

Therapeutic exercise (TE) is recommended in multimodal treatment for patients with non-specific chronic back pain (cLBP).

OBJECTIVE

The aim of this study is to identify an exercise or a spectrum of exercises, well described and reproducible by the clinician, for cLBP patients.

METHODS

Systematic review by researching in the databases MEDLINE, EMBASE, PEDro, CINAHL, and Scopus. Evidence from Randomized Controlled Trials (RCTs) supported the TE in patients with non-specific cLBP, provided that it was well described and could be repeated by another therapist. Methodological evaluation was performed using the PEDro scale and only studies with a score of ⩾ 6 were included. The assessment of the intervention description was carried out with the TIDieR checklist. The risk of bias was examined.

RESULTS

Twenty-one articles were included in this systematic review. The defective description and the poorly reporting of the intervention makes it more difficult for the clinician to include the TE into clinical practice.

CONCLUSIONS

The findings of this study showed that the reporting of the intervention in high quality RCT on chronic low back pain is low, threatening the external validity of the results.

Single-Cell RNA Sequencing Reveals the Difference in Human Normal and Degenerative Nucleus Pulposus Tissue Profiles and Cellular Interactions

Background: The nucleus pulposus is a constituent structure of the human intervertebral disc, and its degeneration can cause intervertebral disc degeneration (IDD). However, the cellular and molecular mechanisms involved remain elusive. Methods: Through bioinformatics analysis, the single-cell transcriptome sequencing expression profiles of human normal nucleus pulposus (NNP) cells and human degenerative nucleus pulposus (DNP) cells were compared to clarify the transcriptome differential expression profiles of human NNP and DNP. The single-cell sequencing results of the two samples were analyzed using bioinformatics methods to compare the differences in histiocytosis between human NNP and DNP, map the histiocytes of NNP and DNP, perform cell differentiation trajectories for the cell populations of interest and predict cell function, and explore their heterogeneity by pathway analysis and Gene Ontology analysis. Results: Nine cell types were identified, which were chondrocyte 1, chondrocyte 2, chondrocyte 3, chondrocyte 4, chondrocyte 5, endothelial, macrophage, neutrophil, and T cells. Analysis of the proportion of chondrocytes in different tissues revealed that chondrocyte 1 accounted for a higher proportion of NNP cells and highly expressed COL2A1 compared with DNP cells; chondrocyte 2, chondrocyte 3, chondrocyte 4, and chondrocyte 5 accounted for a higher proportion of DNP cells compared with NNP cells. Among them, chondrocyte 2 was an inhibitory calcified chondrocyte with high expression of MGP, chondrocytes 3 were fibrochondrocytes with high expression of COL1A1, chondrocytes 4 were chondrocytes that highly express pain inflammatory genes such as PTGES, and chondrocytes 5 were calcified chondrocytes with high expression of FN1 (chondrocytes 4 and chondrocytes 5 were found for the first time in a study of single-cell transcriptome sequencing of disc tissue). Cell trajectory analysis revealed that chondrocyte 1 was at the beginning of the trajectory and chondrocyte 3 was at the end of the trajectory, while chondrocyte 5 appeared first in the trajectory relative to chondrocyte 2 and chondrocyte 4. Conclusion: After functional identification of the specifically expressed genes in five chondrocytes, it was found that chondrocyte 1 was a chondrocyte with high expression of COL2A1, COL9A2, COL11A2, and CHRDL2 in a high proportion of NNP cells, and chondrocyte 3 was a fibrochondrocyte with high expression of COL1A1, COL6A3, COL1A2, COL3A1, AQP1, and COL15A1 in an increased proportion during nucleus pulposus cell degeneration. Through cell trajectory analysis, it was found that chondrocytes 5 specifically expressing FN1, SESN2, and GDF15 may be the key cells leading to degeneration of nucleus pulposus cells. Chondrocytes 2 expressing MGP, MT1G, and GPX3 may play a role in reversing calcification and degeneration, and chondrocytes 4 expressing PTGES, TREM1, and TIMP1 may play a role in disc degeneration pain and inflammation.

Tuina combined with Adjuvant therapy for lumbar disc herniation: A network meta-analysis

OBJECTIVE

To directly or indirectly compare the effectiveness and pain relief of TN combined with different treatments for lumbar disc herniation (LDH).

METHODS

The Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI), Wanfang data, Chinese Biomedical Literature database (CBM), Chinese Scientific Journal Database (VIP), PubMed, Embase, Cochrane library, and Web of Science were searched from inception to July 2020. Only full texts of randomized controlled trials (RCTs) that make comparisons between Tuina and Tuina combined with other methods were included. We extracted trial data and assessed the risk of bias by two reviewers independently. We pooled continuous data in standard mean differences (SMDs) and binary data in risk ratios (RRs), and provided 95% confidence intervals. The primary outcomes were the effectiveness rate. The secondary outcome was pain measurements including visual analog scale (VAS) scores.

RESULTS

Forty-four trials which included 4741 participants and 16 kinds of interventions were selected in our study. Tuina combined with Acupuncture was the most frequently investigated intervention. Five (31%) kindnesces (SMDs) and binary data in risk ratios (RRs), and provided 95% confidence intervals. The primary outcomes were the effectiveness rate. The secondary outcome was pain measurements including visual analog scale (VAS) scores.

RESULTS

Forty-four trials of treatments among 15 increased the healing rate more significantly compared with Tuina(TN), including Tuian combined with Traction and formula(TN + TRA + FM), Tuina combined with formula(TN + FM), Tuina combined with Traction and Acupuncture(ACU + TN + TRA), Tuian combined with Traction(TN + TRA), Tuina combined with Electroacupuncture(EA + TN), Tuina combined with the warm needle(TN + WN), Tuina combined with Acupuncture(ACU + TN). Seven treatments including Tuina combined with Electroacupuncture(EA + TN), Tuian combined with Traction and formula(TN + TRA + FM), Tuina combined with Acupuncture(ACU + TN), Tuina combined with formula(TN + FM), Acupuncture(ACU), Tuian combined with Traction(TN + TRA), Tuina combined with the warm needle(TN + WN) had better effects in reducing pain intensity compared with Tuina, range from 0.01 (95%Crl 0-0.08) for EA + TN to 0.30 (95%Crl 0.20-0.45) for TN + WN.

CONCLUSIONS

According to the comprehensive review, Tuina combined with Traction and formula(TN + TRA + FM) seemed to be the most recommendable treatment which is more affordable and effective. However, all the available evidence was of low quality, so more high-quality studies are expected to confirm the effectiveness.

REGISTRATION NUMBER

PROSPERO CRD42020193068.

More than one third of clinical practice guidelines on low back pain overlap in AGREE II appraisals. Research wasted?

BACKGROUND

Systematic reviews can apply the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool to critically appraise clinical practice guidelines (CPGs) for treating low back pain (LBP); however, when appraisals differ in CPG quality rating, stakeholders, clinicians, and policy-makers will find it difficult to discern a unique judgement of CPG quality. We wanted to determine the proportion of overlapping CPGs for LBP in appraisals that applied AGREE II. We also compared inter-rater reliability and variability across appraisals.

METHODS

For this meta-epidemiological study we searched six databases for appraisals of CPGs for LBP. The general characteristics of the appraisals were collected; the unit of analysis was the CPG evaluated in each appraisal. The inter-rater reliability and the variability of AGREE II domain scores for overall assessment were measured using the intraclass correlation coefficient and descriptive statistics.

RESULTS

Overall, 43 CPGs out of 106 (40.6%) overlapped in seventeen appraisals. Half of the appraisals (53%) reported a protocol registration. Reporting of AGREE II assessment was heterogeneous and generally of poor quality: overall assessment 1 (overall CPG quality) was rated in 11 appraisals (64.7%) and overall assessment 2 (recommendation for use) in four (23.5%). Inter-rater reliability was substantial/perfect in 78.3% of overlapping CPGs. The domains with most variability were Domain 6 (mean interquartile range [IQR] 38.6), Domain 5 (mean IQR 28.9), and Domain 2 (mean IQR 27.7).

CONCLUSIONS

More than one third of CPGs for LBP have been re-appraised in the last six years with CPGs quality confirmed in most assessments. Our findings suggest that before conducting a new appraisal, researchers should check systematic review registers for existing appraisals. Clinicians need to rely on updated CPGs of high quality and confirmed by perfect agreement in multiple appraisals.

TRIAL REGISTRATION

Protocol Registration OSF: https://osf.io/rz7nh/.

Neuromechanical Responses to Spinal Manipulation and Mobilization: A Crossover Randomized Clinical Trial

OBJECTIVE

The purpose of this study was to compare the immediate effect of spinal manipulation (SMa) and spinal mobilization (SMo) on muscular responses, spinal stiffness, and segmental spinal pressure evoked pain in a population of participants with chronic middle back pain (MBP).

METHODS

In a crossover randomized trial, 2 experienced chiropractors assessed whether volunteers were eligible for the protocol according to a list of specific inclusion and exclusion criteria. Individuals with MBP participated in 2 experimental sessions within 72 hours. During the first session, participants randomly received a SMa or SMo delivered by an apparatus using a servolinear motor. During the second session, the other modality was delivered. Spinal stiffness and pressure-provoked pain intensity outcomes were assessed before and after each therapy, and muscular responses were recorded during the treatment using surface electromyographic sensors. Signed-rank Wilcoxon tests for muscular responses and generalized model for repeated measure for spinal stiffness and pressure-provoked pain were used for statistical analyses.

RESULTS

Among the 32 potential participants, 26 (mean age 29.9 [±9.14], 15 women) completed both sessions. Between-group differences were observed for the muscular response amplitude (P < .001), and indeed the normalized RMS muscular response was found to be higher during SMa than SMo. Similar results were observed for pressure-provoked pain intensity at the level of therapeutic modality application (P = .002) as a higher decrease in pain was found after SMa (47.9 [±22.8] to 36.6 [±23.7]) compared with SMo (47.2 [±23.2] to 45.5 [±24.3]). No between-group differences were found for spinal stiffness change, nor for terminal (P = .08) and global spinal stiffness (P = .06).

CONCLUSION

In a controlled environment, spinal manipulation and mobilization generated different muscle responses and had different immediate effects on pressure-provoked pain intensity for subjects with MBP.

An update of current therapeutic approach for Intervertebral Disc Degeneration: A review article

Intervertebral disc degeneration is a natural process of aging. It can cause physical, psychological, and socioeconomic impact due to the decreasing function of the spine and pain manifestation. Conservative and surgical treatment to correct symptoms and structural anomalies does not fully recover the degenerated disc. Several therapeutic approaches have been developed to improve the clinical result and patient's quality of life. This paper aims to review previous studies that discussed potential novel approach in order to make effective degenerated disc restoration. We tried to briefly describe IVD, IDD, also review several promising current therapeutic approaches for degenerated disc treatment, including its relevance to the degeneration process and limitation to be applied in a clinical setting. There are generally four current therapeutic approaches that we reviewed; growth factors, small molecules, gene therapy, and stem cells. These new approaches aim to not only correct the symptoms but also restore and delay the degeneration process.

•

Intervertebral Disc Degeneration.

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Current Therapeutic Approach.

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Stem Cell Therapy.

Presence of Tumor Necrosis Factor-Alpha in Urine Samples of Patients With Chronic Low Back Pain Undergoing Chiropractic Care: Preliminary Findings From a Prospective Cohort Study

Background and aims

Low back pain is the leading cause of years lived with disability worldwide. Chiropractors employ different interventions to treat low back pain, including spinal manipulative therapy, although the mechanisms through which chiropractic care improves low back pain are still unclear. Clinical research and animal models suggest that spinal manipulation might modulate plasma levels of inflammatory cytokines, which have been involved in different stages of low back pain. More specifically, serum levels of Tumor Necrosis Factor-alpha (TNF-α) have been found to be elevated in patients with chronic low back pain. We aimed to investigate whether urine from chronic low back pain patients could be an appropriate medium to measure concentrations of TNF-α and to examine possible changes in its levels associated to chiropractic care.

Methods

Urine samples were collected from 24 patients with chronic low back pain and TNF-α levels were analyzed by ELISA before and after 4-6 weeks of care compared to a reference value obtained from 5 healthy control subjects, by means of a Welch's t-test. Simultaneously, pain intensity and disability were also evaluated before and after care. Paired t-tests were used to compare mean pre and post urinary concentrations of TNF-α and clinical outcomes.

Results

Significantly higher baseline levels of urinary TNF-α were observed in chronic low back pain patients when compared to our reference value (p < 0.001), which were significantly lower after the period of chiropractic treatment (p = 0.03). Moreover, these changes were accompanied by a significant reduction in pain and disability (both p < 0.001). However, levels of urinary TNF-α were not correlated with pain intensity nor disability.

Conclusion

These results suggest that urine could be a good milieu to assess TNF-α changes, with potential clinical implications for the management of chronic low back pain.

Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Meta-analysis

BACKGROUND

Study results vary on whether depressive symptoms are associated with worse prognosis for low back pain (LBP). We assessed the association between depressive symptoms or depression and health outcomes in persons with LBP.

METHODS

We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to June 2020. Eligible studies were cohort and case-control studies assessing the association between depressive symptoms (questionnaires) or depression (diagnoses) and health outcomes in persons aged ≥16 years with LBP in the absence of major pathology. Reviewers independently screened articles, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. We classified exploratory versus confirmatory studies based on phases of prognostic factor investigation. We conducted random-effects meta-analyses and descriptive synthesis where appropriate.

RESULTS

Of 13,221 citations screened, we included 62 studies (63,326 participants; 61 exploratory studies, 1 confirmatory study). For acute LBP, depressive symptoms were associated with self-reported disability (descriptive synthesis: 6 studies), worse recovery (descriptive synthesis: 5 studies), and slower traffic injury-related claim closure (1 study), but not pain or work-related outcomes. Depressive symptoms were associated with greater primary healthcare utilization for acute LBP (1 confirmatory study). For chronic LBP, depressive symptoms were associated with higher pain intensity (descriptive synthesis: 9 studies; meta-analysis: 3 studies, 2902 participants, β=0.11, 95% confidence interval (CI) 0.05-0.17), disability (descriptive synthesis: 6 studies; meta-analysis: 5 studies, 3549 participants, β=0.16, 95% CI 0.04-0.29), and worse recovery (descriptive synthesis: 2 studies; meta-analysis: 2 studies, 13,263 participants, relative risk (RR)=0.91, 95% CI 0.88-0.95), but not incident chronic widespread pain (1 study).

DISCUSSION

Depressive symptoms may be associated with self-reported disability and worse recovery in persons with acute and chronic LBP, and greater primary healthcare utilization for acute LBP. Our review provides high-quality prognostic factor information for LBP. Healthcare delivery that addresses depressive symptoms may improve disability and recovery in persons with LBP. Confirmatory studies are needed to assess the association between depressive symptoms and health outcomes in persons with LBP.

PROTOCOL REGISTRATION

PROSPERO database (CRD42019130047).

Management of acute low back pain in emergency departments in São Paulo, Brazil: a descriptive, cross-sectional analysis of baseline data from a prospective cohort study

OBJECTIVE

To describe management strategies used in public emergency departments in a middle-income country for patients with acute non-specific low back pain.

DESIGN

A descriptive, cross-sectional analysis of baseline data from a prospective cohort study.

SETTING AND PARTICIPANTS

A study with 600 patients with low back pain presenting in four public emergency departments from São Paulo, Brazil was conducted.

OUTCOME MEASURES

Diagnostic tests, pharmacological interventions, and/or referral to other healthcare professionals were collected. Descriptive analyses were used to report all outcomes.

RESULTS

Of all patients, 12.5% (n=75) underwent some diagnostic imaging tests. Medication was administered to 94.7% (n=568) of patients. The most common medications were non-steroidal anti-inflammatory drugs (71.3%; n=428), opioids (29%; n=174) and corticosteroids (22.5%; n=135). Only 7.5% (n=45) of patients were referred to another type of care.

CONCLUSION

There is a need for research data on low back pain from middle-income countries. There was an acceptable rate of prescription for diagnostic imaging tests. However, there were high medication prescriptions and small rates of referrals to other healthcare services. Our findings indicate that there is still a need to implement best practices in the management of acute low back pain at public emergency departments in Brazil.

Curative Effect of Foraminal Endoscopic Surgery and Efficacy of the Wearable Lumbar Spine Protection Equipment in the Treatment of Lumbar Disc Herniation

Lumbar disc herniation is a common and frequently-occurring disease in pain clinics. The incidence rate of affliction is increasing with every passing year. Besides the aged, young people also suffer from long-term pain, which not only affects their daily routines but may also lead to serious impairment. The causes of chronic low back and leg pain caused by lumbar disc herniation are mainly related to mechanical compression, the adhesion of epidural space, intervertebral space, and aseptic inflammatory reaction. The treatment of lumbar disc herniation should follow the principle of step-by-step treatment. An appropriate treatment scheme needs to be adopted according to the patient's condition. About 80% of patients received nonsurgical treatment to get relief from the pain symptoms. However, 10% to 15% of patients still need traditional open surgery. Spinal foraminal surgery is a new method for the treatment of lumbar disc herniation, lumbar surgery failure syndrome, and lumbar spinal stenosis. However, there are only scattered clinical reports on the efficacy of spinal foraminal surgery. Based on it, this paper proposes a method to explore the efficacy of spinal foraminal mirror surgery in the treatment of lumbar disc herniation. Besides, postoperative wearable lumbar protective equipment is proposed to ensure a seamless rehabilitation effect on the patients. Statistical analysis performed using a t-test revealed that there was a significant difference between the visual analog scales (VAS) scores of the two groups after 3 and 6 months of treatment (P < 0.05). The paper analyzes and summarizes the cases with definite and poor curative effects, which not only provides the basis for clinical practice but also paves the way to multicenter clinical research.

Wrist, but Not Back, Isometric Contraction Induced Widespread Hypoalgesia in Healthy Participants

Objective: Exercise may reduce pain sensitivity. This phenomenon called exercise-induced hypoalgesia is observed in different types of exercises and involves the activation of endogenous pain modulation systems. Although the effect of limb exercise on pain sensitivity has often been tested, few studies explored the impact of back exercises that are often used to treat low back pain. The main objective is to measure the effect of back-muscle exercise on pain sensitivity and compare it to the effect of a limb-muscle exercise.

Methods: Twenty-three participants who were pain-free performed a 4-min wrist flexion isometric contraction followed by a 4-min low back extension, separated by a 20-min break. Pressure pain thresholds were tested at two low back (S1 spinous process, lumbar erector spinae muscle) and two wrist (capitate bone, wrist flexor muscles) sites before and after each exercise. For each exercise, sites were considered as remote or local in relation to the muscles contracted during the exercise. An independent sample of 11 participants was recruited to confirm the influence of low back extension on pain sensitivity.

Results: Wrist exercise induced a larger increase in pain sensitivity than back exercise at the remote site. Only wrist exercise induced a hypoalgesia effect at both the local and the remote sites. Back exercise induced a similar effect in the independent sample.

Conclusions: This study showed that back and wrist exercises induced a distinct effect on pain sensitivity in participants who were pain-free. The wrist exercise induced a systemic reduction in pain sensitivity (locally and remotely), whereas the back exercise did not. This differential effect may be present because wrist exercise induced most fatigue compared with the back exercise.

Impact of Non-steroidal Anti-inflammatory Drug Administration for 12 Months on Renal Function

Background: The use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with an increased risk of renal complications. Resolution of renal adverse effects after NSAID administration has been observed after short-term use. Thus, the present study aimed to investigate a series of patients with chronic musculoskeletal pain who underwent long-term NSAID administration followed by switching to tramadol hydrochloride/acetaminophen (TA) combination tablets to study the impact of NSAID-induced renal adverse effects. Methods: This was a longitudinal retrospective study of 99 patients with chronic musculoskeletal pain. The patients were administrated with NSAIDs daily during the first 12 months, followed by daily TA combination tablets for 12 months. Estimated glomerular filtration rate (eGFR) and serum levels of aspartate aminotransferase and alanine transaminase were measured at baseline, after NSAID administration and after TA administration. Results: eGFR was significantly reduced after 12-month NSAID administration (median, from 84.0 to 72.8 ml/min/1.73 m²), and the reduction was not shown after the subsequent 12-month TA administration (median, 71.5 ml/min/1.73 m²). Reduction in eGFR was less in patients who received celecoxib (median, -1.8 ml/min/1.73 m²) during the first 12 months. There was no significant difference in aspartate aminotransferase and alanine transaminase in each period. Conclusions: Thus, patients receiving NSAIDs for 12 months displayed both reversible and irreversible reduction of eGFR upon cessation of NSAIDs and switching to TA. Our data highlight the potential safety benefit of utilizing multimodal analgesic therapies to minimize the chronic administration of NSAIDs.

An Educational and Exercise Mobile Phone–Based Intervention to Elicit Electrophysiological Changes and to Improve Psychological Functioning in Adults With Nonspecific Chronic Low Back Pain (BackFit App): Nonrandomized Clinical Trial

Background

Concomitant psychological and cognitive impairments modulate nociceptive processing and contribute to chronic low back pain (CLBP) maintenance, poorly correlated with radiological findings. Clinical practice guidelines recommend self-management and multidisciplinary educational and exercise-based interventions. However, these recommendations are based on self-reported measurements, which lack evidence of related electrophysiological changes. Furthermore, current mobile health (mHealth) tools for self-management are of low quality and scarce evidence. Thus, it is necessary to increase knowledge on mHealth and electrophysiological changes elicited by current evidence-based interventions.

Objective

The aim of this study is to investigate changes elicited by a self-managed educational and exercise-based 4-week mHealth intervention (BackFit app) in electroencephalographic and electrocardiographic activity, pressure pain thresholds (PPTs), pain, disability, and psychological and cognitive functioning in CLBP versus the same intervention in a face-to-face modality.

Methods

A 2-arm parallel nonrandomized clinical trial was conducted at the University of the Balearic Islands (Palma, Spain). A total of 50 patients with nonspecific CLBP were assigned to a self-managed group (23/50, 46%; mean age 45.00, SD 9.13 years; 10/23, 43% men) or a face-to-face group (27/50, 54%; mean age 48.63, SD 7.54 years; 7/27, 26% men). The primary outcomes were electroencephalographic activity (at rest and during a modified version of the Eriksen flanker task) and heart rate variability (at rest), PPTs, and pressure pain intensity ratings. The secondary outcomes were pain, disability, psychological functioning (mood, anxiety, kinesiophobia, pain catastrophizing, and fear-avoidance beliefs), and cognitive performance (percentage of hits and reaction times).

Results

After the intervention, frequency analysis of electroencephalographic resting-state data showed increased beta-2 (16-23 Hz; 0.0020 vs 0.0024; P=.02) and beta-3 (23-30 Hz; 0.0013 vs 0.0018; P=.03) activity. In addition, source analyses revealed higher power density of beta (16-30 Hz) at the anterior cingulate cortex and alpha (8-12 Hz) at the postcentral gyrus and lower power density of delta (2-4 Hz) at the cuneus and precuneus. Both groups also improved depression (7.74 vs 5.15; P=.01), kinesiophobia (22.91 vs 20.87; P=.002), activity avoidance (14.49 vs 12.86; P<.001), helplessness (6.38 vs 4.74; P=.02), fear-avoidance beliefs (35 vs 29.11; P=.03), and avoidance of physical activity (12.07 vs 9.28; P=.01) scores, but there was an increase in the disability score (6.08 vs 7.5; P=.01). No significant differences between the groups or sessions were found in heart rate variability resting-state data, electroencephalographic data from the Eriksen flanker task, PPTs, subjective ratings, or cognitive performance.

Conclusions

Both intervention modalities increased mainly beta activity at rest and improved psychological functioning. Given the limitations of our study, conclusions must be drawn carefully and further research will be needed. Nevertheless, to the best of our knowledge, this is the first study reporting electroencephalographic changes in patients with CLBP after an mHealth intervention.

Trial Registration

ClinicalTrials.gov NCT04576611; https://clinicaltrials.gov/ct2/show/NCT04576611

The 3-Month Effectiveness of a Stratified Blended Physiotherapy Intervention in Patients With Nonspecific Low Back Pain: Cluster Randomized Controlled Trial

Background

Patient education, home-based exercise therapy, and advice on returning to normal activities are established physiotherapeutic treatment options for patients with nonspecific low back pain (LBP). However, the effectiveness of physiotherapy interventions on health-related outcomes largely depends on patient self-management and adherence to exercise and physical activity recommendations. e-Exercise LBP is a recently developed stratified blended care intervention comprising a smartphone app integrated with face-to-face physiotherapy treatment. Following the promising effects of web-based applications on patients’ self-management skills and adherence to exercise and physical activity recommendations, it is hypothesized that e-Exercise LBP will improve patients’ physical functioning.

Objective

This study aims to investigate the short-term (3 months) effectiveness of stratified blended physiotherapy (e-Exercise LBP) on physical functioning in comparison with face-to-face physiotherapy in patients with nonspecific LBP.

Methods

The study design was a multicenter cluster randomized controlled trial with intention-to-treat analysis. Patients with nonspecific LBP aged ≥18 years were asked to participate in the study. The patients were treated with either stratified blended physiotherapy or face-to-face physiotherapy. Both interventions were conducted according to the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients’ risk of developing persistent LBP using the Keele STarT Back Screening Tool. The primary outcome was physical functioning (Oswestry Disability Index, range 0-100). Secondary outcomes included pain intensity, fear-avoidance beliefs, and self-reported adherence. Measurements were taken at baseline and at the 3-month follow-up.

Results

Both the stratified blended physiotherapy group (104/208, 50%) and the face-to-face physiotherapy group (104/208, 50%) had improved clinically relevant and statistically significant physical functioning; however, there was no statistically significant or clinically relevant between-group difference (mean difference −1.96, 95% CI −4.47 to 0.55). For the secondary outcomes, stratified blended physiotherapy showed statistically significant between-group differences in fear-avoidance beliefs and self-reported adherence. In patients with a high risk of developing persistent LBP (13/208, 6.3%), stratified blended physiotherapy showed statistically significant between-group differences in physical functioning (mean difference −16.39, 95% CI −27.98 to −4.79) and several secondary outcomes.

Conclusions

The stratified blended physiotherapy intervention e-Exercise LBP is not more effective than face-to-face physiotherapy in patients with nonspecific LBP in improving physical functioning in the short term. For both stratified blended physiotherapy and face-to-face physiotherapy, within-group improvements were clinically relevant. To be able to decide whether e-Exercise LBP should be implemented in daily physiotherapy practice, future research should focus on the long-term cost-effectiveness and determine which patients benefit most from stratified blended physiotherapy.

Trial Registration

ISRCTN Registry 94074203; https://doi.org/10.1186/ISRCTN94074203

International Registered Report Identifier (IRRID)

RR2-https://doi.org/10.1186/s12891-020-3174-z

The Roles of circRNAs in Intervertebral Disc Degeneration: Inflammation, Extracellular Matrix Metabolism, and Apoptosis

Low back pain (LBP) is seriously harmful to human health and produces heavy economic burden. And most scholars hold that intervertebral disc degeneration (IDD) is the primary cause of LBP. With the study of IDD, aberrant expression of gene has become an important pathogenic factor of IDD. Circular RNAs (circRNAs), as a kind of noncoding RNA (ncRNA), participate in the regulation of genetic transcription and translation and further affect the expression of inflammatory cytokine, metabolism of extracellular matrix (ECM), the proliferation and apoptosis of cells, etc. Therefore, maybe it will become a new therapeutic target for IDD. At present, our understanding of the mechanism of circRNAs in IDD is limited. The purpose of this review is to summarize the mechanism and related signaling pathways of circRNAs in IDD reported in the past. Particularly, the roles of circRNAs in inflammation, ECM metabolism, and apoptosis are emphasized.

Scoping review of evidence for managing postnatal hypoglycaemia

OBJECTIVES

To identify what is known empirically about the screening, treatment and harm of exposure to neonatal hypoglycaemia.

DESIGN

Scoping review that applied a preregistered protocol based on established frameworks.

DATA SOURCES

Medline and Embase, up to 12 May 2020.

STUDY SELECTION

Comparative and case-series studies, as well as guidelines, published in English or French, on the topic of immediate inpatient postnatal glucose screening in newborns.

DATA GATHERING

Article selection and characterisation were performed in duplicate using predefined data extraction forms specific to primary studies and guidelines.

RESULTS

12 guidelines and 74 primary studies were included. A neurodevelopmental outcome was primary in 32 studies: 30 observational studies followed up posthypoglycaemic, and the 2 intervention studies included 1 randomised controlled trial (RCT) about treatment thresholds. Three other RCTs assessed dextrose gel (two) and oral sucrose (one). 12 of 30 studies that evaluated non-neurodevelopmental primary outcomes were intervention studies. Only one cohort study compared outcomes in screened vs unscreened newborns. The guidelines did not arrive at a consensus definition of postnatal hypoglycaemic, and addressed potential harms of screening more often than primary studies.

CONCLUSIONS

The primary literature that informs hypoglycaemia screening is a series of studies that relate neurodevelopmental outcomes to postnatal hypoglycaemia. Further research is needed to better define an optimal threshold for hypoglycaemia that warrants intervention, based on long-term neurodevelopmental outcomes and a better delineation of potential screening harms.

Influence of education level on the effectiveness of pain neuroscience education: A secondary analysis of a randomized controlled trial

BACKGROUND

Current evidence supports the use of pain neuroscience education (PNE) in several chronic pain populations. However, the effects of PNE at group level are rather small and little is known about the influence of personal factors (e.g. level of education [LoE]).

OBJECTIVE

To examine whether the effectiveness of PNE differs in chronic spinal pain (CSP) patients with high LOE (at least a Bachelor's degree) versus lower educated patients.

METHOD

A total of 120 Belgian CSP patients were randomly assigned to the experimental (PNE) or control group (biomedical-focused neck/back school). Participants within each group were further subcategorized based on highest achieved LoE. ANOVA and Bonferroni post-hoc analyses were used to evaluate differences in effectiveness of the interventions between higher and lower educated participants.

RESULTS

No differences between higher and lower educated participants were identified for pain-related disability. Significant interactions (P < .05) were found for kinesiophobia and several illness perceptions components. Bonferroni post-hoc analysis revealed a significant improvement in kinesiophobia (P < .001 and P < .002, medium effect sizes) and perceived negative consequences (P < .001 and P < .008, small effect sizes) in the PNE groups. Only the higher education PNE group showed a significant improvement in perceived illness cyclicity (P = .003, small effect size). Post-treatment kinesiophobia was significant lower in the higher educated PNE group compared to the higher educated control group (p < .001).

CONCLUSION

Overall, the exploratory findings suggest no clinical meaningful differences in effectiveness of PNE between higher and lower educated people. PNE is effective in improving kinesiophobia and several aspects of illness perceptions regardless of LoE.

Using Intervention Mapping to Develop a Decision Support System–Based Smartphone App (selfBACK) to Support Self-management of Nonspecific Low Back Pain: Development and Usability Study

Background

International guidelines consistently endorse the promotion of self-management for people with low back pain (LBP); however, implementation of these guidelines remains a challenge. Digital health interventions, such as those that can be provided by smartphone apps, have been proposed as a promising mode of supporting self-management in people with chronic conditions, including LBP. However, the evidence base for digital health interventions to support self-management of LBP is weak, and detailed descriptions and documentation of the interventions are lacking. Structured intervention mapping (IM) constitutes a 6-step process that can be used to guide the development of complex interventions.

Objective

The aim of this paper is to describe the IM process for designing and creating an app-based intervention designed to support self-management of nonspecific LBP to reduce pain-related disability.

Methods

The first 5 steps of the IM process were systematically applied. The core processes included literature reviews, brainstorming and group discussions, and the inclusion of stakeholders and representatives from the target population. Over a period of >2 years, the intervention content and the technical features of delivery were created, tested, and revised through user tests, feasibility studies, and a pilot study.

Results

A behavioral outcome was identified as a proxy for reaching the overall program goal, that is, increased use of evidence-based self-management strategies. Physical exercises, education, and physical activity were the main components of the self-management intervention and were designed and produced to be delivered via a smartphone app. All intervention content was theoretically underpinned by the behavior change theory and the normalization process theory.

Conclusions

We describe a detailed example of the application of the IM approach for the development of a theory-driven, complex, and digital intervention designed to support self-management of LBP. This description provides transparency in the developmental process of the intervention and can be a possible blueprint for designing and creating future digital health interventions for self-management.

Promoting the use of a self-management strategy among novice chiropractors treating individuals with spine pain: A mixed methods pilot clustered-clinical trial

Background

The uptake of Self-Management Support (SMS) among clinicians is suboptimal. To date, few studies have tested knowledge translation (KT) interventions to increase the application of SMS in chiropractic teaching clinics.

Study objective

Evaluate the feasibility of implementing a KT intervention to promote the use of a SMS strategy among chiropractic interns, their supervisors, and individuals with spine pain compared to controls.

Methods

Mixed methods pilot clustered-clinical trial. Clusters of 16 Patient Management Teams were allocated to a complex KT intervention (online and workshop training). Primary feasibility outcomes for clinicians, interns and patients were rates of recruitment, retention, and adherence to protocol. A nominal group technique and interviews were used to seek end-users’ views on the implementation process, and generate possible solutions.

Results

In total, 16 (84%) clinicians, 65 (26%) interns and 42 patients agreed to participate. All clinicians in the intervention group completed all KT intervention components, 23 interns (85%) completed the online training and 14 interns (51.8%) attended the workshop training. All clinicians in the intervention and seven (78%) in the control group completed all outcome measures at baseline and 6-month follow-up, while 15 (55.6%) and 23 (60.5%) interns in the intervention and control groups completed the questionnaires at baseline and 6-month follow-up, respectively. Among patients, 10 (52.6%) and 12 (52.2%) in the intervention and control groups respectively completed the questionnaires at the end of the study. Based on interview findings, solutions to improve the feasibility of conducting a full trial include: making SMS a part of the internship, changing the time of introducing the study to the interns, and having more training on SMS.

Conclusion

Recruitment and retention of chiropractic interns and patients for a larger implementation trial in a single outpatient teaching clinic may be challenging.

IMMEDIATE ANALGESIC EFFECT OF 4KHZ AMFS INTERFERENTIAL CURRENT ON CHRONIC LOW BACK PAIN

ABSTRACT Objective: To analyze the immediate effect of amplitude modulation frequencies (AMFs) of 4kHz interferential current (IFC) on chronic low back pain (CLBP). Method: This is a randomized controlled clinical trial. Sixty-three subjects with CLBP were recruited. The subjects were randomized into 3 groups: the placebo group (PG, n=21) and 2 intervention groups (IG), IG4kHz/2Hz (n=21) and IG4kHz/100Hz (n=21). All groups were submitted to a single session of 30 minutes. Pain was evaluated using a numerical rating scale (NRS), the McGill Pain Questionnaire (MPQ), and pressure algometry. Flexibility was evaluated using the Modified Schober Test (MST), the Sit-and-Reach Test (SRT), the Fingertip-to-Floor Test (FTF), and the Passive Straight-Leg Raise Test (PSLR). Results: Comparing IG4kHz/100Hz with PG, we found a significant difference (p<0.05) in NRS in the total and in the MPQ categories, whereas in the comparison between IG4kHz/2Hz and PG, we found a significant difference only in the sensory and evaluative categories of MPQ. Regarding the flexibility tests, we observed a significant difference of both IG4kHz/100Hz and IG4kHz/2Hz in comparison to PG in MST and PSLR, and of IG4kHz/2Hz in comparison to PG in SRT. The 4kHz IFC was effective in immediately reducing CLBP and, consequently, in increasing the flexibility of the lumbar spine and lower limbs. Conclusion: Conclusion: There was a greater number of significant positive outcomes when the 100Hz AMF was adopted. Level of Evidence I; High quality randomized clinical trial with or without statistically significant differences, but with narrow confidence intervals.

Predictors for physical activity and its change after active physical therapy in people with spinal pain and insomnia: Secondary analysis of a randomized controlled trial

BACKGROUND

In healthy people and people with nonspecific chronic spinal pain (nCSP) and/or insomnia, participation in physical activity on a regular basis has several physical and psychological health benefits. However, people with chronic conditions often tend to reduce physical activity participation which can lead to deconditioning over time. Currently, there are no known predictors for an (in)active lifestyle (before and after physical therapy treatment) in people with chronic spinal pain and comorbid insomnia.

OBJECTIVE

To examine predictors of pre-treatment moderate-to-vigorous physical activity (MVPA) and to examine determinants for a change in MVPA in response to 14-weeks of active physical therapy treatment in people with nonspecific chronic spinal pain (nCSP) and comorbid insomnia.

METHODS

Baseline data and post-treatment data were analyzed for 66 participants. A linear multiple regression analysis was conducted to examine which factors predict MVPA at baseline. Linear mixed-effects modeling was used to identify determinants for change in MVPA in response to an active physical therapy treatment.

RESULTS

Physical fatigue (b = -0.9; 95%CI: -1.59, -0.15), less limitations in functioning as a result of emotional problems (b = 0.1; 95%CI: 0.03, 0.10), mental fatigue (b = -1.0; 95%CI: -1.67, -0.43), lower general sleep quality (b= 0.7; 95%CI: 0.22, 1.17), and body mass index (b = -0.5; 95%CI: -0.93, -0.16) were significant predictors of baseline MVPA. The regression model explained 33.3% of the total variance in baseline MVPA. The change of MVPA in response to the treatment ranged from a decrease of 17.5 to an increase of 16.6 hours per week. No determinants for change in MVPA after treatment could be identified.

CONCLUSION

People with nCSP and comorbid insomnia are more likely to engage in MVPA if they report, at baseline, lower sleep quality, fewer limitations in functioning resulting from emotional problems, lower body mass index, as well as less physical and mental fatigue.

Involving practice nurse and other assistant clinical staff members in the management of low back pain: A qualitative interview study from Danish general practice

Objectives

Involving practice nurse and other assistant clinical staff members in providing information and education to patients with low back pain at follow-up appointments may release more time and improve care in general practice. However, this requires a shift in the division of tasks, and general practitioners' barriers and facilitators for this are currently unknown. The objectives were to explore general practitioners' experiences and perceptions of including assistant clinical staff members in the management of low back pain.

Methods

This is a semi-structured interview study in Danish general practice. General practitioners with a variation in demographics and experience with task-delegation to clinical staff were recruited for in-depth interviews. We used a phenomenological approach to guide the data collection and the analysis in order to gain insight into the subjective experiences of the general practitioners and to understand the phenomenon of 'delegating tasks to practice staff' from the perspective of the general practitioners' lifeworld. Analysis was conducted using an inductive descriptive method. The sample size was guided by information power.

Results

We conducted five interviews with general practitioners. All general practitioners had experience with task delegation, but there was a variation in which tasks the general practitioners delegated and to which types of clinical staff members. The following themes were derived from the analysis: general practice organisation, delegating to clinical staff members, doctor-patient relationship, exercise instruction, clinical pathway for patients and external support.

Conclusion

General practitioners consider patients with low back pain to be a heterogeneous group with a variety of treatment needs and a patient group without any predetermined content or frequency of consultations; this can be a barrier for delegating these patients to clinical staff members.

Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients With Nonacute Musculoskeletal Conditions? A Systematic Rapid Review

OBJECTIVE

To determine whether nonpharmacologic interventions delivered through synchronous telehealth are as effective and safe compared with in-person interventions for the management of patients with musculoskeletal conditions in improving pain, functioning, self-reported recovery, psychological outcomes, or health-related quality of life using rapid review methods.

DATA SOURCES

We searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials from 2010 to August 2020 for randomized controlled trials (RCTs) published in English or French; we updated our search in January 2021.

STUDY SELECTION

One reviewer screened citations in 2 phases (phase 1: title/abstract; phase 2: full-text) selecting RCTs comparing synchronous telehealth with in-person care for the management of musculoskeletal conditions. A random 10% sample was screened by 2 independent reviewers with minimum 95% agreement prior to full screening. One reviewer critically appraised and one reviewer validated appraisal for eligible RCTs.

DATA EXTRACTION

One author extracted participant characteristics, setting, sample size, interventions, comparisons, follow-up period, and outcome data. A second author validated data extraction.

DATA SYNTHESIS

We summarized the findings narratively. Low- to moderate-quality evidence suggests that synchronous telehealth (ie, videoconference or telephone calls) alone or in combination with in-person care leads to similar outcomes as in-person care alone for nonspecific low back pain, generalized osteoarthritis, hip or knee osteoarthritis, and nonacute headaches in adults.

CONCLUSIONS

Synchronous telehealth may be an option for the management of nonacute musculoskeletal conditions in adults. However, our results may not be generalizable to rural or low socioeconomic populations. Future research should investigate the outcomes associated the use of new technologies, such as videoconference.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Efficacy of metamizole versus ibuprofen and a short educational intervention versus standard care in acute and subacute low back pain: a study protocol of a randomised, multicentre, factorial trial (EMISI trial)

INTRODUCTION

Low back pain (LBP) is among the top three most common diseases worldwide, resulting in a life with pain-related disability. To date, no study has assessed the efficacy of metamizole (dipyrone), a non-opioid analgesic and antipyretic prodrug compared with the conventional non-steroidal anti-inflammatory drug ibuprofen, in patients with an acute LBP episode. Further, it is unclear, whether a short educational intervention is superior to usual care alone.

OBJECTIVES

The objective of this study is to assess first, whether metamizole is non-inferior to ibuprofen in a new episode of acute or subacute LBP. Second, we aim to assess whether a short educational intervention including evidence-based patient information on the nature of LBP is superior to usual care alone.

METHODS AND ANALYSIS

An investigator-initiated multicentre, randomised, double blind trial using a factorial design will be performed. A total of 120 participants with a new episode of LBP will be recruited from GP practices, outpatient clinics and from emergency departments, and randomised into four different treatment groups: ibuprofen alone, ibuprofen and short intervention, metamizole alone, metamizole and short intervention. The primary endpoint for the medical treatment will be change in pain assessed on an 11-point Numeric Rating Scale after 14 days. The primary outcome for the short intervention will be change in the Core Outcome Measures Index assessed after 42 days.

ETHICS, DISSEMINATION AND FUNDING

This study has been approved by the responsible Ethics Board (Ethikkommission Bern/2018-01986) and the Swiss Agency for Therapeutic Products (Swissmedic/2019DR4002). Results will be published in open access policy peer-reviewed journals. The study is funded by the Swiss National Science Foundation (grant number 32 003B-179346).

TRIAL REGISTRATION NUMBER

NCT04111315.

Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study

OBJECTIVE

To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED.

METHODS

We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions.

RESULTS

Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care.

CONCLUSION

We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

A Novel Exercise Facilitation Method in Combination with Cognitive Behavioral Therapy Using the Ikiiki Rehabilitation Notebook for Intractable Chronic Pain: Technical Report and 22 Cases

Recent clinical practice guidelines for chronic pain indicate, with a high evidence level, that the combination of exercise and cognitive behavioral therapy (CBT) is effective. The purpose of this study was to evaluate the effectiveness of an exercise facilitation method in combination with CBT using the "Ikiiki Rehabilitation Notebook" for patients with intractable chronic pain. "Ikiiki" means active in Japanese. A total of 22 cases with chronic low back (n = 13), lower extremity (n = 8), or neck (n = 1) pain were treated using this notebook. Two cases dropped out, leaving 22 cases. Each case was evaluated in terms of the numerical rating scale (NRS) of the pain, activities of daily living (ADL), pain catastrophizing scale (PCS), and quality of life (QOL) at pretreatment and post-treatment. The endpoint of the method was to achieve the long-term goals set by the patients. The mean treatment period was 11.2 months. The outcomes were as follows: improvement of presenteeism: nine cases; enhanced participation in hobbies: seven cases; improved school attendance: two cases; return to work: one case; improvement of self-care and/or self-efficacy: three cases. The NRS, ADL, PCS, and QOL were significantly improved after the treatment. This method is possibly valuable for educating patients about the cause and treatment of chronic pain and actively facilitating exercise and social participation. Further studies are needed to investigate the effectiveness of using this notebook for the patient with intractable chronic pain.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Predicting nonrecovery in adults with incident traffic injuries including post-traumatic headache

IMPORTANCE

The management of traffic injuries is challenging for clinicians. Knowledge about predictors of nonrecovery from traffic injuries may help to improve patient care.

OBJECTIVE

To develop a prediction model for self-reported overall nonrecovery from traffic injuries six months post-collision in adults with incident traffic injuries including post-traumatic headache (PTH).

DESIGN

Inception cohort studies of adults with incident traffic injuries (including PTH) injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada; and between January 2004 and January 2005 in Sweden.

METHODS

Prediction model development and geographical external validation.

SETTING

The Saskatchewan cohort (development) was population-based (N = 4,162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20% of cars driven in Sweden in 2004.

PARTICIPANTS

All adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized > 2 days, lost consciousness > 30 min, or reported headache < 3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80%.

PREDICTORS

Baseline sociodemographic, pre-injury, and injury factors.

OUTCOME

Self-reported nonrecovery from all injuries (not "all better (cured)" on the self-perceived recovery scale) six months after traffic collision.

RESULTS

Both cohorts were predominantly female (69.8% in Saskatchewan, 65.2% in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, low back pain, symptoms in arms or hands, hearing problems, sleeping problems, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.85 probability), the model can rule in the presence of self-reported nonrecovery from all injuries at six months (development: specificity = 91.3%, 95% CI 89.2%-93.0%; sensitivity = 27.8%, 95% CI 26.0%-29.7%; positive likelihood ratio (LR + ) = 3.2, 95% CI 2.5-4.0; negative likelihood ratio (LR-) = 0.79, 95% CI 0.76-0.82; validation: specificity = 72.6%, 95% CI 61.4%-81.5%; sensitivity = 60.5%, 95% CI 53.9%-66.7%); LR+ = 2.2, 95% CI 1.5-3.3; LR- = 0.5, 95% CI 0.4-0.7).

CONCLUSIONS AND RELEVANCE

In adults with incident traffic injuries including PTH, predictors other than those related to baseline head and neck pain drive overall nonrecovery. Developing and testing interventions targeted at the modifiable predictors may help to improve outcomes for adults after traffic collision.

Establishing a critical pathway for Korean medical management of lumbar disc herniation: A modified Delphi consensus process

A modified Delphi method was used to establish a consensus. Stakeholders and experts were invited to participate in the expert panel. Best practice statements and decision-making questionnaires were distributed to the panel. Panel members were asked to mark "Strongly disagree" to "Strongly agree" after a series of statements over several rounds until either a consensus was reached or the decision-making method was deemed unsuitable for reaching a consensus.The most common cause of lumbar pain is intervertebral degeneration, which leads to degenerative disc disease and lumbar disc herniation. There is a lack of unanimity regarding appropriate patient protocols and rehabilitation expectations for Korean medical care. The long-term viability of Korean medical treatment, further adoption in the institutional setting, and specific patient outcomes are contingent on the existence of appropriate Korean medical programs.A Korean medical expert panel of 17 practitioners employed a modified Delphi method to achieve consensus on Korean medical care for lumbar disc herniation. The panel first reviewed the literature and guidelines relevant to Korean medical treatment for lumbar disc herniation. The panel members considered questionnaires intended to determine "standardized" Korean medical care recommendations for patients with a wide range of symptoms of lumbar disc herniation. Each panel member participated in a round of voting, which was followed by an opinion-collecting session online. Consensus was defined as a ≥75% agreement among the respondents.In the first round, 144 questionnaires across 5 domains were administered to the expert panels. After reviewing the responses and open-ended comments collected in the first round, the authors modified the questionnaires to 53 items and proceeded. In round 2, consensus was achieved in all 53 survey questions. The final treatment pathway comprised a standardized and comprehensive care approach for lumbar disc herniations in 4 types of medical institutions.This study identified a core set of evidence- and consensus-based principles that are essential to a comprehensive model of care, incorporating identification, referral, and management of patients with lumbar disc herniation.

A process evaluation of the Mind Your Back trial examining psychologically informed physical treatments for chronic low back pain

Background

In chronic conditions, such as back pain, the use of interventions that address physical, social and psychological aspects within a biopsychosocial framework are encouraged, however, applying this holistic multimodal approach in physical therapy practice (i.e., chiropractic and physiotherapy) is challenging. To explore the problem of delivering a biopsychosocially informed package of care in physical therapy practice a recent randomised control trial (RCT) called ‘Mind Your Back’ was conducted to evaluate the effectiveness of a combined physical and internet-delivered psychological intervention (psychologically informed physical treatments) compared to standard treatment for improving disability and self-efficacy in people with chronic LBP. The results of the trial indicated no difference between the two intervention groups. Although high-quality RCTs are considered gold standard for effectiveness of interventions, qualitative research methods embedded within a process evaluation framework are also used to reveal other issues and important information that help to explain clinical trial results, and to further the field of digital health interventions research. Therefore, within a process evaluation framework, the aim is to explore participants experiences of the interventions received throughout the Mind Your Back trial which led to a null result.

Methods

In-line with recommendations for a process evaluation this study used in-depth interviews and qualitative thematic analysis with participants of both arms of the trial 5–6 months after study completion. Semi-structured telephone interviews were conducted with twenty-five participants to explore their experiences of taking part in the Mind Your Back trial. Interviews were conducted in November 2017, transcribed verbatim and data analysed thematically.

Results

Two main themes were identified: (1) Personalised support and therapeutic alliance are important, and (2) MoodGYM lacked relevant, personalised and tailored support.

Conclusion

It is important to deliver tailored digital health supports that is personalised and fosters a therapeutic alliance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00389-y.

Predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus: A prospective study in Indonesia

BACKGROUND

The objective of this study was to identify the predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus (HNP).

METHODS

A prospective study was conducted between June 2010 and April 2012 in Banda Aceh, Indonesia. Clinical and baseline neurologic examinations such as passive straight leg raising test (SLRT), cross SLRT, and patellar and Achilles reflexes were assessed prior to the conservative management. The patients were evaluated at 2nd, 4th, 8th, 12th and 24th week following commencement of the conservative management.

RESULTS

We recruited and followed 171 HNP patients of which 35.7% of them had good outcome. At univariate analysis, patients with more than 12 months duration of complaint, those with dominant radicular pain, severe pain intensity (visual analogue scale 7-10), positive SLRT, positive cross SLRT, and reduced motor power of knee extensors (muscle strength grade 1-4), were associated with poor outcome. Multivariate analysis suggested that patients with dominant radicular type of pain were likely to had poor outcome compared to those with dominant back pain (odd ratio (OR) 10.57 with 95% confidence interval (CI) 1.15-96.93). Patients with reduced motor power of knee extensors also had a higher chance to have poor outcome compared to those who were normal (OR: 10.57; 95% CI: 1.15-96.93).

CONCLUSION

Type of pain and the strength of lower extremities could be able to predict the failure of conservative management in patients with lumbar disc herniation. However, further studies with the bigger sample size are warrant to validate our results.

Reassuring Patients With Low Back Pain in Primary Care Consultations: Does it Happen, and Does it Matter? A ChiCo Cohort Study

OBJECTIVES

Reassurance is an important part of treatment for low back pain (LBP). The Consultation-based Reassurance Questionnaire measures patients' perceived reassurance after health care consultations on 4 subdomains (ie, Data-gathering, Relationship-building, Generic reassurance, Cognitive reassurance). The objectives of this study were to investigate associations between the level of reassurance and outcomes and to investigate if the associations were moderated by patients' risk profile.

MATERIALS AND METHODS

Adult patients consulting chiropractors for LBP were emailed the Consultation-based Reassurance Questionnaire directly after the consultation. Outcomes were Global Perceived Effect (GPE) after 2 weeks, and pain (Numeric Rating Scale) and disability (Roland-Morris Disability Questionnaire) 2 weeks and 3 months following treatment. Associations with GPE were tested in logistic mixed models. Associations between each reassurance domain and pain and disability were tested in longitudinal analyses using linear mixed models. Moderations by risk profile were tested by introducing an interaction between risk groups and reassurance level. All models were controlled for several potential confounders.

RESULTS

A total of 2056 patients were included in the study, with 46% reporting LBP for less than a week. Associations between reassurance level and improvement in LBP intensity and disability were weak but positive, whereas associations with GPE were potentially clinically relevant. None of the associations were moderated by psychological risk profile.

DISCUSSION

Identified associations between reassurance and outcomes were weak, however, for GPE the association might be of a clinically relevant magnitude. The causal relationship is unclear, but with communication always present in a consultation these results suggest that efforts to optimize clinician-patient communication might be worthwhile, also for people with very recent onset of LBP.

Paracetamol: A Review of Guideline Recommendations

Musculoskeletal pain conditions are age-related, leading contributors to chronic pain and pain-related disability, which are expected to rise with the rapid global population aging. Current medical treatments provide only partial relief. Furthermore, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in young and otherwise healthy individuals but are often contraindicated in elderly and frail patients. As a result of its favorable safety and tolerability record, paracetamol has long been the most common drug for treating pain. Strikingly, recent reports questioned its therapeutic value and safety. This review aims to present guideline recommendations. Paracetamol has been assessed in different conditions and demonstrated therapeutic efficacy on both acute and chronic pain. It is active as a single agent and is additive or synergistic with NSAIDs and opioids, improving their efficacy and safety. However, a lack of significant efficacy and hepatic toxicity have also been reported. Fast dissolving formulations of paracetamol provide superior and more extended pain relief that is similar to intravenous paracetamol. A dose reduction is recommended in patients with liver disease or malnourished. Genotyping may improve efficacy and safety. Within the current trend toward the minimization of opioid analgesia, it is consistently included in multimodal, non-opioid, or opioid-sparing therapies. Paracetamol is being recommended by guidelines as a first or second-line drug for acute pain and chronic pain, especially for patients with limited therapeutic options and for the elderly.

What Does the Psychological Flexibility Model Contribute to the Relationship Between Depression and Disability in Chronic Pain? The Role of Cognitive Fusion and Pain Acceptance

This study examines the mediator role of cognitive fusion between depressive symptoms, activity avoidance and excessive persistence at different levels of pain acceptance (moderator) among fibromyalgia patients (FM). Using a sample of 231 women, multiple and moderate mediation analyses were conducted with PROCESS. Results showed that depression was positively associated with activity avoidance and excessive persistence. Furthermore, cognitive fusion and pain acceptance were found to mediate the effect of depression in both patterns. Additionally, pain acceptance was found to play a contextual role in cognitive fusion, as a moderator, between depressive symptoms and maladaptive patterns. Specifically, FM patients with high acceptance levels and low levels of depression presented the strongest associations between depression and cognitive fusion. Techniques aimed at reducing cognitive fusion, could be especially beneficial to FM women with high pain acceptance.

Effectiveness of non-pharmacological interventions on sleep characteristics among adults with musculoskeletal pain and a comorbid sleep problem: a systematic review

Sleep problems are common and may be associated with persistent pain. It is unclear whether non-pharmacological interventions improve sleep and pain in adults with comorbid sleep problems and musculoskeletal (MSK) pain. We conducted a systematic review on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and comorbid sleep problems. We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and PsycINFO from inception to April 2, 2021 for randomized controlled trials (RCTs), cohort, and case-control studies. Pairs of independent reviewers critically appraised and extracted data from eligible studies. We synthesized the findings qualitatively. We screened 8459 records and identified two RCTs (six articles, 467 participants). At 9 months, in adults with insomnia and osteoarthritis pain, cognitive behavioral therapy for pain and insomnia (CBT-PI) was effective at improving sleep (Insomnia Severity Index, ISI) when compared to education (OR 2.20, 95% CI 1.25, 3.90) or CBT for pain (CBT-P) (OR 3.21, 95% CI 1.22, 8.43). CBP-P vs. education was effective at increasing sleep efficiency (wrist actigraphy) in a subgroup of participants with severe pain at baseline (mean difference 5.45, 95% CI 1.56, 9.33). At 18 months, CBT-PI, CBT-P and education had similar effectiveness on sleep and pain or health outcomes. In adults with insomnia and knee osteoarthritis, CBT-I improved some sleep outcomes including sleep efficiency (diary) at 3 months (Cohen's d 0.39, 95% CI 0.24, 1.18), and self-reported sleep quality (ISI) at 6 months (Cohen's d - 0.62, 95% CI -1.01, - 0.07). The intervention was no better than placebo (behavioural desensitization) for improving other sleep outcomes related to sleep onset or pain outcomes. Short-term improvement in sleep was associated with pain reduction at 6 months (WOMAC pain subscale) (sensitivity 54.8%, specificity 81.4%). Overall, in two acceptable quality RCTs of adults with OA and comorbid insomnia, CBT-PI/I may improve some sleep outcomes in the short term, but not pain outcomes in the short or long-term. Clinically significant improvements in sleep in the short term may improve longer term pain outcomes. Further high-quality research is needed to evaluate other non-pharmacological interventions for people with comorbid sleep problems and a range of MSK conditions.

Quality changes of clinical practice guidelines for respiratory diseases in China: A systematic review

BACKGROUND

After the low quality of Chinese clinical practice guidelines (CPGs) for respiratory diseases published from 1979 to 2013 was reported, some handbooks were published to standardize guidelines' development recently. There was a great increase in the production and dissemination of CPGs annually in China, whose quality and potential impact were unknown.

METHODS

A systematic search of four literature databases was performed for the period January 2013 to December 2018 to identify Chinese CPGs for respiratory diseases. Eligible CPGs were evaluated using the appraisal of guidelines for research and evaluation II (AGREE II) instrument.

RESULTS

A total of 197 CPGs were identified for review. Compared with the result of previous study, the increased scores of the six AGREE II domains were screened: Scope and purpose (57.3% vs. 57.8%), Stakeholder involvement (17.6% vs. 25.0%), Rigor of development (10.2% vs. 13.2%), Clarity and presentation (55.2% vs. 58.4%), Applicability (9.3% vs. 25.9%), and Editorial independence (1.1% vs. 6.3%). The improved overall assessment for included CPGs were: Recommended (4, 2.0% vs. 0, 0%) and Recommended with modifications (26, 13.2% vs. 3, 2.8%). The improved level of evidence used to make recommendations were 59, 11.9% versus 168, 22.4% and 88, 17.7% versus 195, 26.0%, A and B, respectively.

CONCLUSIONS

The overall quality of CPGs for respiratory diseases published from 2013 to 2018 in China was slightly improved, but had a big gap with the optimum level, especially in Rigor of development and Editorial independence. Increased efforts are required to enable the development of high-quality evidence-based CPGs for respiratory diseases.

Exercise interventions for low back pain are poorly reported: a systematic review

OBJECTIVE

To assess the reporting quality of exercise interventions from clinical trials of low back pain (LBP).

STUDY DESIGN AND SETTING

We conducted a systematic review to assess the reporting quality of randomised controlled trials (RCTs) that investigated the effectiveness of exercise interventions for patients with LBP. Five online databases and Clinical Trial Registries were searched (October 2018). We included RCTs that reported interventions for LBP, containing at least 50% exercise. The Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) reporting checklists were then used to assess quality of reporting.

RESULTS

582 trials were eligible for inclusion. Due to the large number of eligible studies, 100 studies were randomly selected for data extraction and coding with the TIDieR and CERT checklists. The random sample was representative of the 582 eligible trials. The overall completeness of reporting (median (IQR)) of TIDieR items was 59.2% (45.5%-72.7%) and CERT was 33.3% (22.2%-52.6%).

CONCLUSIONS

We found poor overall reporting with both checklists, which has not improved over time or since the introduction of the checklists. More dedicated work is required to address poor reporting of exercise interventions in clinical trials.

"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND

Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed.

OBJECTIVE

The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making.

DESIGN

This was an exploratory interview study using inductive content analysis.

METHOD

Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity).

CONCLUSION

This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

Photobiomodulation therapy is not better than placebo in patients with chronic nonspecific low back pain: a randomised placebo-controlled trial

ABSTRACT

Photobiomodulation therapy (PBMT) has been used in several musculoskeletal disorders to reduce pain, inflammation, and promoting tissue regeneration. The current evidence about the effects of PBMT on low back pain (LBP) is still conflicting. We aimed to evaluate the effects of PBMT against placebo on pain intensity and disability in patients with chronic nonspecific LBP. This was a prospectively registered, randomised placebo-controlled trial, with blinded patients, therapists, and assessors. The study was conducted on an outpatient physical therapy clinic in Brazil, between April 2017 and May 2019. A total of 148 patients with chronic nonspecific LBP were randomised to either active PBMT (n = 74) or placebo (n = 74). Patients from both groups received 12 treatment sessions, 3 times a week, for 4 weeks. Patients from both groups also received an educational booklet based on "The Back Book." Clinical outcomes were measured at baseline and at follow-up appointments at 4 weeks, 3, 6, and 12 months after randomisation. The primary outcomes were pain intensity and disability measured at 4 weeks. We estimated the treatment effects using linear mixed models following the principles of intention-to-treat. There was no clinical important between-group differences in terms of pain intensity (mean difference = 0.01 point; 95% confidence interval = -0.94 to 0.96) and disability (mean difference = -0.63 points; 95% confidence interval = -2.23 to 0.97) at 4 weeks. Patients did not report any adverse events. Photobiomodulation therapy was not better than placebo to reduce pain and disability in patients with chronic nonspecific LBP.

Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review

Context

Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence.

Aim

To identify determinants of clinical practice guidelines’ utilization by health care providers involved in the assessment and management of MSDs.

Method

A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines’ utilization were extracted from selected articles.

RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with “non-specific” term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician’s interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language.

Conclusion

Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04204-w.

Online Videos as a Source of Physiotherapy Exercise Tutorials for Patients with Lumbar Disc Herniation-A Quality Assessment

Background: During the last few decades the prevalence of lumbar disc herniation has been increasing constantly, thereby imposing a significant socioeconomic burden. Physiotherapy plays a crucial role in both surgical and conservative treatment of lumbar disc herniation, consequently the current COVID-19 pandemic with concomitant lockdowns has led to a shortage of physiotherapeutical care. In the light of these recent events publicly available physiotherapy tutorials may be a useful tool to address this problem. Aim: The main aim of this study was to assess the quality of online physiotherapy exercise tutorials for lumbar disc herniation. Materials & Methods: With YouTube being a widely known and used platform we screened 240 of the most viewed videos. A total of 76 videos met the inclusion criteria and were statistically analyzed. The videos were assessed using Global Quality Score, DISCERN Score and JAMA benchmark criteria and in regard to their applicability. Results: They displayed a wide range of views (44,969 to 5,448,717), likes (66 to 155,079) and dislikes (6 to 2339). The videos were assessed using Global Quality Score, DISCERN Score and JAMA benchmark criteria and in regard to their applicability. Neither the number of "Views", "Likes", nor "Dislikes" was found to have a significant association with any of the quality measures used in this study. Conclusion: Overall quality grade was determined as "moderate". Based on the data examined in this study, the use of YouTube videos as a source of therapy advice for lumbar spine disc herniation cannot be recommended universally.

Clinical guidelines and care pathway for management of low back pain with or without radicular pain

OBJECTIVE

To develop guidelines for low back pain management according to previous international guidelines and the updated literature.

METHODS

A report was compiled from a review of systematic reviews of guidelines published between 2013 and 2018 and meta-analysis of the management of low back pain published between 2015 and 2018. This report summarized the state-of-the-art scientific knowledge for each predefined area of the guidelines from a critical review of selected literature. A multidisciplinary panel of experts including 17 health professionals involved in low back pain management and 2 patient representatives formulated preliminary guidelines based on the compilation report and a care pathway. The compilation report and preliminary guidelines were submitted to 25 academic institutions and stakeholders for the consultation phase. From responses of academic institutions and stakeholders, the final guidelines were developed. For each area of the guidelines, agreement between experts was assessed by the RAND/UCLA method.

RESULTS

The expert panel drafted 32 preliminary recommendations including a care pathway, which was amended after academic institution and stakeholder consultation. The consensus of the multidisciplinary expert panel was assessed for each final guideline: 32 recommendations were assessed as appropriate; none was assessed as uncertain or inappropriate. Strong approval was obtained for 27 recommendations and weak for 5.

CONCLUSION

These new guidelines introduce several concepts, including the need to early identify low back pain at risk of chronicity to provide quicker intensive and multidisciplinary management if necessary.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation

BACKGROUND

Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs.

OBJECTIVES

The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice.

METHODS

We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process.

RESULTS

We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP.

CONCLUSIONS

We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

Effects of acupoint massage combined with relaxation therapy on patients with postoperative fatigue syndrome after lumbar surgery

BACKGROUND

: Lumbar disc herniation (LDH) is a common disease in orthopedics. Surgery is shown to provide significant faster relief of pain compared to conservative therapy. However, due to the influence of surgical trauma, anesthesia and other perioperative stress factors, patients may have complications. Among them, postoperative fatigue syndrome (POFS) is a common complication. Traditional Chinese medicine or integrated traditional Chinese and Western medicine have been proved to be effective in improving postoperative fatigue.

METHODS

: This study is a randomized controlled trial. One hundred eighty Chinese patients with POFS of LDH will be randomly divided into control group, experimental group 1, experimental group 2 and experimental group 3 according to the ratio of 1:1:1:1. The patients in the control group will be treated with conventional treatment after operation, the patients in the experimental group 1 will be treated with acupoint massage, the patients in the experimental group 2 will be treated with relaxation therapy, and the patients in the experimental group 3 will be treated with acupoint massage combined with relaxation therapy. The whole treatment will last for 5 days. The main outcome measures will be fatigue visual analogue scale and identity-consequence fatigue scale, and the secondary outcome measures will be hospital anxiety and depression scale.

DISCUSSION

: This study is to observe the effects of acupoint massage comblined with relaxation therapy on reducing postoperative fatigue of lumbar disc herniation surgical patients.

TRIAL REGISTRATION

: Chinese Clinical Trial Registry (http://www.chictr.org.cn/edit.aspx?pid=123978&htm=4), No. ChiCTR2100044788. Registered on March 27, 2021.