Effect sizes of non-surgical treatments of non-specific low-back pain

A pilot study to determine the effect of one physical therapy session on physical activity levels for individuals with chronic low back pain

Background

A pilot study was conducted to quantify the effect size of changes in physical activity after of one session of physical therapy for individuals with chronic low back pain and to determine factors that predict daily sedentary activity time.

Methods

Fourteen subjects with at least 3 days of physical activity accelerometer data were analyzed before and after one session of physical therapy. Data was analyzed using 1-tailed, paired t-tests with level of significance set at 0.05. Effect sizes were computed using the baseline and post intervention mean differences divided by the baseline and post-intervention differences in the standard deviation.

Results

A nonsignificant reduction in steps-per-day and time spent performing sedentary activities, with increases in light and moderate–vigorous physical activity were found (effect size: 0.15–0.33). A nonsignificant decrease in daily sitting and standing time 1 week immediately following the physical therapy session and an increase in daily lying time (p = 0.03) (effect size: 0.23–0.69) were found.

Conclusion

One physical therapy session resulted in a small physical activity change for individuals with chronic low back pain. Baseline and post intervention levels of pain catastrophisation and perceptions of disability need to be explored in future studies to determine if these are factors that influence levels of physical activity change for these individuals Results are limited by the small sample size, however the ability to increase physical activity in this population may be of clinical relevance.

Trial Registration NCT02823756; June 30, 2016: Retrospectively Registered

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3006-x) contains supplementary material, which is available to authorized users.

The Need for Multidimensional Stratification of Chronic Low Back Pain (LBP)

MINI: The authors wanted to determine which existing primary-care low back pain stratification schema is associated with distinct subpopulations. Initial stratification by DMPP identified potentially distinct epidemiological groups. DMPP stratification resulted in discrimination beyond that provided by disability or chronicity risk stratification alone.

STUDY DESIGN

A cross-sectional study of Canadian patients suffering from low back pain (LBP) seeking primary care.

OBJECTIVE

The aim of this study was to determine which existing primary care LBP stratification schema is associated with distinct subpopulations as characterized by easily identifiable primary epidemiological factors.

SUMMARY OF BACKGROUND DATA

LBP is among the most frequent reasons for visits to primary care physicians and a leading cause of years lived with disability. In an effort to improve treatment response/outcomes in LBP primary care, different classification systems have been proposed in an effort to provide more tailored treatment with the intent of improving outcomes. Group-specific risk factors and underlying etiology might suggest a need for, or inform, changes to treatment approaches to optimize LBP outcomes.

METHODS

Stratification by dominant mechanical pain patterns; chronicity risk; disability severity. Multinomial logistic regression was used to identify the system showing greatest variability in associations with age, sex, obesity, and comorbidity. Once identified, the remaining schemas were incorporated into the model.

RESULTS

N = 970; mean age: 50 years (range: 18-93); 56% female. Stratification by pain pattern revealed greater variability. Adjusted analysis: Increasing age was associated with greater odds of intermittent, extension-based back- or leg-dominant pain [odds ratio (OR): 1.02 and 1.06; P < 0.01]; being male with leg-dominant pain (ORs > 2; P < 0.01). Overweight/obesity was associated with extension-based leg-dominant pain (OR = 2.6; P < 0.02) and increasing comorbidity with extension-based back-dominant pain (OR = 1.3; P < 0.01). Severe disability was associated only with constant leg pain (OR = 3.9; P < 0.01), and high chronicity risk with extension-based leg-dominant pain (OR = 0.4; P = 0.03).

CONCLUSION

Dominant mechanical symptom stratification resulted in further discrimination of an epidemiologically distinct and a large subgroup of LBP patients not identified by disability or chronicity risk stratification alone. Findings suggest a need for primary care initiated multidimensional stratification in chronic LBP.

LEVEL OF EVIDENCE

3.

Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

OBJECTIVE

To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP).

DESIGN

Single-blind randomized controlled trial.

SETTING

Private clinic and university.

PARTICIPANTS

Patients with CLBP for ≥6 months (N=56).

INTERVENTIONS

Participants were randomized to receive either a TE program consisting of motor control, stretching, and aerobic exercises (n=28) or the same TE program in addition to a PNE program (n=28), conducted in two 30- to 50-minute sessions in groups of 4 to 6 participants.

MAIN OUTCOMES MEASURES

The primary outcome was pain intensity rated on the numerical pain rating scale which was completed immediately after treatment and at 1- and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Patient Global Impression of Change.

RESULTS

At 3-month follow-up, a large change in pain intensity (numerical pain rating scale: -2.2; -2.93 to -1.28; P<.001; d=1.37) was observed for the PNE plus TE group, and a moderate effect size was observed for the secondary outcome measures.

CONCLUSIONS

Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone.

Applying contemporary neuroscience in exercise interventions for chronic spinal pain: treatment protocol

BACKGROUND

Nonspecific chronic spinal pain is a common problem within the chronic pain population and is characterized by high social, economic and personal impact. To date, therapists are still struggling in adequately treating these types of patients, as seen in the small and short-term benefits of frequently applied primary care treatments. It is remarkable that despite the well-documented presence of abnormalities in central nociceptive processing in nonspecific chronic spinal pain patients, the implementation of this knowledge in clinical practice is still nearly non-existent.

METHODS

This paper provides the treatment protocol used in a large randomized controlled trial that aimed to assess the effectiveness of a modern neuroscience approach compared to usual care evidence-based physiotherapy. This comprehensive pain neuroscience treatment program combines pain neuroscience education and cognition-targeted exercise therapy.

CONCLUSION

Based on previous small-scaled studies, this treatment protocol is expected to normalize central alterations by addressing central nervous system dysfunctions, psychological factors, as well as peripheral dysfunctions in a broader biopsychosocially-driven framework.

Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature

Background

Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines.

Methods

A scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using “physiotherapy”, “occupational therapy”, “therapeutic alliance”, and “musculoskeletal” to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study.

Results

One hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.

Conclusion

Therapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2311-3) contains supplementary material, which is available to authorized users.

The Placebo Analgesic Effect in Healthy Individuals and Patients: A Meta-Analysis

OBJECTIVE

The present meta-analysis investigates whether the magnitude of placebo analgesia is different in patients compared with healthy individuals and whether placebo analgesia is different in experimentally induced pain compared with clinical pain in patients.

METHODS

A literature search in Web of Science (ISI) on the terms "placebo analgesia" and "placebo analgesic" was conducted. The search resulted in 71 studies, including 4239 participants. Fifty-five studies included healthy individuals and 16 studies included patients. Of the 16 studies with patients, five studies investigated clinical pain and 11 studies investigated experimentally induced pain.

RESULTS

The average effect size was 1.24 for healthy individuals and 1.49 for patients. In the studies with patients, the average effect sizes of placebo treatment were 1.73 for experimentally induced pain and 1.05 for clinical pain. A χ test revealed that there were relatively more studies with patients compared with healthy volunteers in which there was a clinically significant reduction in pain (p = .040).

CONCLUSIONS

The findings suggest that patients benefited from placebo treatment to a greater degree than healthy individuals did and that studies on healthy individuals may underestimate the magnitude of the placebo analgesic effect in patients. Patients' clinical pain and experimentally induced pain respond to placebo to the same degree.

Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context

This commentary explores the importance of considering the biopsychosocial model and contextual factors when prescribing exercise. Diverse exercise programs for patients with chronic low back pain (CLBP) produce similar outcomes, without one specific exercise protocol demonstrating clear superiority. One clear barrier to positive outcomes is poor exercise adherence. We suggest that there are certain common contextual factors present in all exercise prescription scenarios that may impact adherence and health-related outcomes. While challenging common core stability exercise prescription, we present an argument for enhancing and intentionally shaping the following contextual factors: the therapeutic alliance, patient education, expectations and attributions of therapeutic success or failure, and mastery or cognitive control over a problem. Overall, this commentary argues that to improve exercise adherence and outcomes in the CLBP population, the context in which exercise is delivered and the meaning patients embody need to be considered and shaped by clinicians.

Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial

STUDY DESIGN

Economic evaluation of a randomized clinical trial.

OBJECTIVE

Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy.

SUMMARY OF BACKGROUND DATA

Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown.

METHODS

Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs.

RESULTS

Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY.

CONCLUSION

Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP.

LEVEL OF EVIDENCE

2.

Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain

Background

Heterogeneity in patients with low back pain (LBP) is well recognised and different approaches to subgrouping have been proposed. Latent Class Analysis (LCA) is a statistical technique that is increasingly being used to identify subgroups based on patient characteristics. However, as LBP is a complex multi-domain condition, the optimal approach when using LCA is unknown. Therefore, this paper describes the exploration of two approaches to LCA that may help improve the identification of clinically relevant and interpretable LBP subgroups.

Methods

From 928 LBP patients consulting a chiropractor, baseline data were used as input to the statistical subgrouping. In a single-stage LCA, all variables were modelled simultaneously to identify patient subgroups. In a two-stage LCA, we used the latent class membership from our previously published LCA within each of six domains of health (activity, contextual factors, pain, participation, physical impairment and psychology) (first stage) as the variables entered into the second stage of the two-stage LCA to identify patient subgroups. The description of the results of the single-stage and two-stage LCA was based on a combination of statistical performance measures, qualitative evaluation of clinical interpretability (face validity) and a subgroup membership comparison.

Results

For the single-stage LCA, a model solution with seven patient subgroups was preferred, and for the two-stage LCA, a nine patient subgroup model. Both approaches identified similar, but not identical, patient subgroups characterised by (i) mild intermittent LBP, (ii) recent severe LBP and activity limitations, (iii) very recent severe LBP with both activity and participation limitations, (iv) work-related LBP, (v) LBP and several negative consequences and (vi) LBP with nerve root involvement.

Conclusions

Both approaches identified clinically interpretable patient subgroups. The potential importance of these subgroups needs to be investigated by exploring whether they can be identified in other cohorts and by examining their possible association with patient outcomes. This may inform the selection of a preferred LCA approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1411-x) contains supplementary material, which is available to authorized users.

Generic prognostic factors for musculoskeletal pain in primary care: a systematic review

OBJECTIVES

To summarise the evidence for generic prognostic factors across a range of musculoskeletal (MSK) conditions.

SETTING

primary care.

METHODS AND OUTCOMES

Comprehensive systematic literature review. MEDLINE, CINAHL, PsychINFO and EMBASE were searched for prospective cohort studies, based in primary care (search period-inception to December 2015). Studies were included if they reported on adults consulting with MSK conditions and provided data on associations between baseline characteristics (prognostic factors) and outcome. A prognostic factor was identified as generic when significantly associated with any outcome for 2 or more different MSK conditions. Evidence synthesis focused on consistency of findings and study quality.

RESULTS

14 682 citations were identified and 78 studies were included (involving more than 48 000 participants with 18 different outcome domains). 51 studies were on spinal pain/back pain/low back pain, 12 on neck/shoulder/arm pain, 3 on knee pain, 3 on hip pain and 9 on multisite pain/widespread pain. Total quality scores ranged from 5 to 14 (mean 11) and 65 studies (83%) scored 9 or more. Out of a total of 78 different prognostic factors for which data were provided, the following factors are considered to be generic prognostic factors for MSK conditions: widespread pain, high functional disability, somatisation, high pain intensity and presence of previous pain episodes. In addition, consistent evidence was found for use of pain medications not to be associated with outcome, suggesting that this factor is not a generic prognostic factor for MSK conditions.

CONCLUSIONS

This large review provides new evidence for generic prognostic factors for MSK conditions in primary care. Such factors include pain intensity, widespread pain, high functional disability, somatisation and movement restriction. This information can be used to screen and select patients for targeted treatment in clinical research as well as to inform the management of MSK conditions in primary care.

Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors

BACKGROUND/AIM

Stroke is a leading cause of disability in developed countries. One of the most widespread techniques in clinical practice is mirror therapy (MT). To determine the effectiveness of MT over other methods of intervention in the recovery of upper limb function in people who have had a stroke.

METHODS

A systematic review was conducted. The search string was established based on the last systematic review about MT that dated from 2009: "upper extremity" OR "upper limb "AND "mirror therapy" AND stroke. For this search Pubmed, Scopus and SciELO databases were used.

RESULTS

Fifteen studies were included in the systematic review. Recovery of the upper limb, upper limb function and gross manual dexterity were frequently measured in these studies.

CONCLUSIONS

In the primary variables in promoting recovery, MT alone showed better results in acute and chronic stroke patients in upper limb functioning than either conventional rehabilitation (CR) or CR plus MT. PROSPERO registration number: CRD42015026869.

Current and future perspectives on lumbar degenerative disc disease: a UK survey exploring specialist multidisciplinary clinical opinion

OBJECTIVES

Despite lumbar degenerative disc disease (LDDD) being significantly associated with non-specific low back pain and effective treatment remaining elusive, specialist multidisciplinary clinical stakeholder opinion remains unexplored. The present study examines the views of such experts.

DESIGN

A reliable and valid electronic survey was designed to establish trends using theoretical constructs relating to current assessment and management practices. Clinicians from the Society of Back Pain Research (SBPR) UK were invited to take part. Quantitative data were collated and coded using Bristol Online Surveys (BOS) software, and content analysis was used to systematically code and categorise qualitative data.

SETTING

Specialist multidisciplinary spinal interest group in the UK.

PARTICIPANTS

38/141 clinically active, multidisciplinary SBPR members with specialist spinal interest participated. Among them, 84% had >9 years postgraduate clinical experience.

INTERVENTIONS

None.

OUTCOME MEASURES

Frequency distributions were used to establish general trends in quantitative data. Qualitative responses were coded and categorised in relation to each theme and percentage responses were calculated.

RESULTS

LDDD symptom recurrence, in the absence of psychosocial influence, was associated with physical signs of joint stiffness (26%), weakness (17%) and joint hypermobility (6%), while physical factors (21%) and the ability to adapt (11%) were postulated as reasons why some experience pain and others do not. No one management strategy was supported exclusively or with consensus. Regarding effective modalities, there was no significant difference between allied health professional and medic responses (p=0.1-0.8). The future of LDDD care was expressed in terms of improvements in patient communication (35%), patient education (38%) and treatment stratification (24%).

CONCLUSIONS

Results suggest that multidisciplinary expert spinal clinicians appear to follow UK-based assessment guidelines with regard to recurrent LDDD; there are, however, inconsistencies in the management approaches supported. This reflects the current literature and the lack of specific, formalised guidance. LDDD treatment stratification and further research are explicitly supported.

Treatment of Lower Back Pain-The Gap between Guideline-Based Treatment and Medical Care Reality

Despite the fact that unspecific low back pain is of important impact in general health care, this pain condition is often treated insufficiently. Poor efficiency has led to the necessity of guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). We present some statements of the German medical care reality. Self-responsible action of the patient should be supported while invasive methods in particular should be avoided due to lacking evidence in outcome efficiency. However, it has to be stated that no effective implementation strategy has been established yet. Especially, studies on the economic impact of different implementation strategies are lacking. A lack of awareness of common available guidelines and an uneven distribution of existing knowledge throughout the population can be stated: persons with higher risk suffering from LBP by higher professional demands and lower educational level are not skilled in advised management of LBP. Both diagnostic imaging and invasive treatment methods increased dramatically leading to increased costs and doctor workload without being associated with improved patient functioning, severity of pain or overall health status due to the absence of a functioning primary care gate keeping system for patient selection. Opioids are prescribed on a grand scale and over a long period. Moreover, opioid prescription is not indicated properly, when predominantly persons with psychological distress like somatoform disorders are treated with opioids.

Using existing questionnaires in latent class analysis: should we use summary scores or single items as input? A methodological study using a cohort of patients with low back pain

Background

Latent class analysis (LCA) is increasingly being used in health research, but optimal approaches to handling complex clinical data are unclear. One issue is that commonly used questionnaires are multidimensional, but expressed as summary scores. Using the example of low back pain (LBP), the aim of this study was to explore and descriptively compare the application of LCA when using questionnaire summary scores and when using single items to subgrouping of patients based on multidimensional data.

Materials and methods

Baseline data from 928 LBP patients in an observational study were classified into four health domains (psychology, pain, activity, and participation) using the World Health Organization’s International Classification of Functioning, Disability, and Health framework. LCA was performed within each health domain using the strategies of summary-score and single-item analyses. The resulting subgroups were descriptively compared using statistical measures and clinical interpretability.

Results

For each health domain, the preferred model solution ranged from five to seven subgroups for the summary-score strategy and seven to eight subgroups for the single-item strategy. There was considerable overlap between the results of the two strategies, indicating that they were reflecting the same underlying data structure. However, in three of the four health domains, the single-item strategy resulted in a more nuanced description, in terms of more subgroups and more distinct clinical characteristics.

Conclusion

In these data, application of both the summary-score strategy and the single-item strategy in the LCA subgrouping resulted in clinically interpretable subgroups, but the single-item strategy generally revealed more distinguishing characteristics. These results 1) warrant further analyses in other data sets to determine the consistency of this finding, and 2) warrant investigation in longitudinal data to test whether the finer detail provided by the single-item strategy results in improved prediction of outcomes and treatment response.

Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis

Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Ten electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP.

PERSPECTIVE

In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions.

Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15-year time-series study

OBJECTIVES

Low back pain (LBP), from degenerative lumbar spine disease, represents a significant burden on healthcare resources. Studies worldwide report trends attributable to their country's specific demographics and healthcare system. Considering England's specific medico-socioeconomic conditions, we investigate recent trends in hospital admissions and procedures for LBP, and discuss the implications for the allocation of healthcare resources.

DESIGN

Retrospective cohort study using Hospital Episode Statistics data relating to degenerative lumbar spine disease in England, between 1999 and 2013. Regression models were used to analyse trends.

OUTCOME MEASURES

Trends in the number of admissions and procedures for LBP, mean patient age, gender and length of stay.

RESULTS

Hospital admissions and procedures have increased significantly over the study period, from 127.09 to 216.16 and from 24.5 to 48.83 per 100,000, respectively, (p<0.001). The increase was most marked in the oldest age groups with a 1.9 and 2.33-fold increase in admissions for patients aged 60-74 and ≥ 75 years, respectively, and a 2.8-fold increase in procedures for those aged ≥ 60 years. Trends in hospital admissions were characterised by a widening gender gap, increasing mean patient age, and decreasing mean hospital stay (p<0.001). Trends in procedures were characterised by a narrowing gender gap, increasing mean patient age (p=0.014) and decreasing mean hospital stay (p<0.001). Linear regression models estimate that each hospital admission translates to 0.27 procedures, per 100,000 (95% CI 0.25 to 0.30, r 0.99, p<0.001; r, Pearson's correlation coefficient). Hospital admissions are increasing at 3.5 times the rate of surgical procedures (regression gradient 7.63 vs 2.18 per 100,000/year).

CONCLUSIONS

LBP represents a significant and increasing workload for hospitals in England. These trends demonstrate an increasing demand for specialists involved in the surgical and non-surgical management of this disease, and highlight the need for services capable of dealing with the increased comorbidity burden associated with an ageing patient group.

Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review

PURPOSE

Magnetic resonance imaging (MRI) can reveal a range of degenerative findings and anatomical abnormalities; however, the clinical importance of these remains uncertain and controversial. We aimed to investigate if the presence of MRI findings identifies patients with low back pain (LBP) or sciatica who respond better to particular interventions.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched. We included RCTs investigating MRI findings as treatment effect modifiers for patients with LBP or sciatica. We excluded studies with specific diseases as the cause of LBP. Risk of bias was assessed using the criteria of the Cochrane Back Review Group. Each MRI finding was examined for its individual capacity for effect modification.

RESULTS

Eight published trials met the inclusion criteria. The methodological quality of trials was inconsistent. Substantial variability in MRI findings, treatments and outcomes across the eight trials prevented pooling of data. Patients with Modic type 1 when compared with patients with Modic type 2 had greater improvements in function when treated by Diprospan (steroid) injection, compared with saline. Patients with central disc herniation when compared with patients without central disc herniation had greater improvements in pain when treated by surgery, compared with rehabilitation.

CONCLUSIONS

Although individual trials suggested that some MRI findings might be effect modifiers for specific interventions, none of these interactions were investigated in more than a single trial. High quality, adequately powered trials investigating MRI findings as effect modifiers are essential to determine the clinical importance of MRI findings in LBP and sciatica (

PROSPERO

CRD42013006571).

What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies

OBJECTIVES

The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain.

METHODS

Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis.

RESULTS

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.

DISCUSSION

People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Movement-based subgrouping in low back pain: synergy and divergence in approaches

BACKGROUND

Classification systems for low back pain (LBP) aim to guide treatment decisions. In physiotherapy, there are five classification schemes for LBP which consider responses to clinical movement examination. Little is known of the relationship between the schemes.

OBJECTIVES

To investigate overlap between subgroups of patients with LBP when classified using different movement-based classification schemes, and to consider how participants classified according to one scheme would be classified by another.

DESIGN

Cross-sectional cohort study.

SETTING

University clinical laboratory.

PARTICIPANTS

One hundred and two participants with LBP were recruited from university, hospital outpatient and private physiotherapy clinics, and community advertisements.

INTERVENTION

Participants underwent a standardised examination including questions and movement tests to guide subgrouping.

MAIN OUTCOME MEASURES

Participants were allocated to a LBP subgroup using each of the five classification schemes: Mechanical Diagnosis and Treatment (MDT), Movement System Impairment (MSI), O'Sullivan Classification (OSC), Pathoanatomic Based Classification (PBC) and Treatment Based Classification (TBC).

RESULTS

There was concordance in allocation to subgroups that consider pain relief from direction-specific repeated spinal loading in the MDT, PBC and TBC schemes. There was consistency of subgrouping between the MSI and OSC schemes, which consider pain provocation to specific movement directions. Synergies between other subgroups were more variable. Participants from one subgroup could be subdivided using another scheme.

CONCLUSIONS

There is overlap and discordance between LBP subgrouping schemes that consider movement. Where overlap is present, schemes recommend different treatment options. Where subgroups from one scheme can be subdivided using another scheme, there is potential to further guide treatment. An integrated assessment model may refine treatment targeting.

The effect of changing movement and posture using motion-sensor biofeedback, versus guidelines-based care, on the clinical outcomes of people with sub-acute or chronic low back pain-a multicentre, cluster-randomised, placebo-controlled, pilot trial

Background

The aims of this pilot trial were to (i) test the hypothesis that modifying patterns of painful lumbo-pelvic movement using motion-sensor biofeedback in people with low back pain would lead to reduced pain and activity limitation compared with guidelines-based care, and (ii) facilitate sample size calculations for a fully powered trial.

Methods

A multicentre (8 clinics), cluster-randomised, placebo-controlled pilot trial compared two groups of patients seeking medical or physiotherapy primary care for sub-acute and chronic back pain. It was powered for longitudinal analysis, but not for adjusted single-time point comparisons. The intervention group (n = 58) received modification of movement patterns augmented by motion-sensor movement biofeedback (ViMove, dorsaVi.com) plus guidelines-based medical or physiotherapy care. The control group (n = 54) received a placebo (wearing the motion-sensors without biofeedback) plus guidelines-based medical or physiotherapy care.

Primary outcomes were self-reported pain intensity (VAS) and activity limitation (Roland Morris Disability Questionnaire (RMDQ), Patient Specific Functional Scale (PSFS)), all on 0–100 scales. Both groups received 6–8 treatment sessions. Outcomes were measured seven times during 10-weeks of treatment and at 12, 26 and 52 week follow-up, with 17.0 % dropout. Patients were not informed of group allocation or the study hypothesis.

Results

Across one-year, there were significant between-group differences favouring the intervention group [generalized linear model coefficient (95 % CI): group effect RMDQ −7.1 (95 % CI–12.6;–1.6), PSFS −10.3 (−16.6; −3.9), QVAS −7.7 (−13.0; −2.4); and group by time effect differences (per 100 days) RMDQ −3.5 (−5.2; −2.2), PSFS −4.7 (−7.0; −2.5), QVAS −4.8 (−6.1; −3.5)], all p < 0.001. Risk ratios between groups of probability of improving by >30 % at 12-months = RMDQ 2.4 (95 % CI 1.5; 4.1), PSFS 2.5 (1.5; 4.0), QVAS 3.3 (1.8; 5.9).

The only device-related side-effects involved transient skin irritation from tape used to mount motion sensors.

Conclusions

Individualised movement retraining using motion-sensor biofeedback resulted in significant and sustained improvements in pain and activity limitation that persisted after treatment finished. This pilot trial also refined the procedures and sample size requirements for a fully powered RCT.

This trial (Australian New Zealand Clinical Trials Registry NCT01572779) was equally funded by dorsaVi P/L and the Victorian State Government.

Efficacy and safety of nicoboxil/nonivamide ointment for the treatment of acute pain in the low back - A randomized, controlled trial

Background

Until now, nonivamide/nicoboxil ointment has not been tested in a randomized trial for the treatment of acute non‐specific low back pain.

Methods

This phase III randomized, double‐blind, active‐ and placebo‐controlled, multi‐centre trial investigated efficacy, safety and tolerability of topical nicoboxil 2.5%/nonivamide 0.4% for treatment of acute non‐specific low back pain [primary endpoint: pain intensity (PI) difference between pre‐dose baseline and 8 h after the first application].

Results

Patients (n = 805), 18–74 years of age were treated for up to 4 days with nicoboxil 2.5%/nonivamide 0.4%, nicoboxil 2.5%, nonivamide 0.4% or placebo ointment. Pre‐dose baseline pain intensity (6.6 on a 0‐ to 10‐point numerical rating scale) was reduced by 1.049 points with placebo, by 1.428 points with nicoboxil, by 2.252 points with nonivamide and by 2.410 points with nicoboxil/nonivamide after 8 h (p < 0.0001 for nicoboxil/nonivamide vs. placebo, nicoboxil; p = 0.4171 for nicoboxil/nonivamide vs. nonivamide). At the end of treatment, the combination provided more pronounced PI reduction (3.540 points) compared with nicoboxil (2.371, p < 0.0001), nonivamide (3.074, p = 0.0259) and placebo (1.884, p < 0.0001). Low back mobility scores on Day 1 were better for the combination compared with all other treatments (p < 0.044); on Day 2–4, scores were better than for placebo and nicoboxil (p < 0.003). Patients assessed efficacy of the combination as greater than of the comparators (p ≤ 0.0129). All treatments were tolerated well. No treatment‐related serious adverse events were reported.

Conclusion

Nicoboxil/nonivamide ointment is an effective, well‐tolerated medication for the treatment of acute non‐specific low back pain.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies

INTRODUCTION

Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice.

OBJECTIVES

To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain.

METHODS AND ANALYSIS

A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014.

ETHICS AND DISSEMINATION

Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice.

TRIAL REGISTRATION NUMBER

PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961.

Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To evaluate the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) for the management of neck pain and associated disorders (NAD), whiplash-associated disorders, and non-specific low back pain (LBP) with or without radiculopathy.

METHODS

We systematically searched six databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible systematic reviews using the Scottish Intercollegiate Guidelines Network criteria. We included systematic reviews with a low risk of bias in our best evidence synthesis.

RESULTS

We screened 706 citations and 14 systematic reviews were eligible for critical appraisal. Eight systematic reviews had a low risk of bias. For recent-onset NAD, evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy. For NAD (duration not specified), oral NSAIDs may be more effective than placebo. For recent-onset LBP, evidence suggests that: (1) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant; and (2) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest. For persistent LBP, evidence suggests that: (1) oral NSAIDs are more effective than placebo; and (2) oral NSAIDs may be more effective than acetaminophen. For recent-onset LBP with radiculopathy, there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo. Finally, different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy.

CONCLUSIONS

For NAD, oral NSAIDs may be more effective than placebo. Oral NSAIDs are more effective than placebo for persistent LBP, but not for recent-onset LBP. Different oral NSAIDs lead to similar outcomes for neck pain and LBP.

Acupuncture for low back pain: an overview of systematic reviews

Objective. As evidence of the effectiveness of acupuncture for low back pain (LBP) is inconsistent, we aimed to critically appraise the evidence from relevant systematic reviews. Methods. Systematic reviews of randomized controlled trials (RCTs) concerning acupuncture and LBP were searched in seven databases. Internal validity and external validity of systematic reviews were assessed. Systematic reviews were categorized and high quality reviews assigned greater weightings. Conclusions were generated from a narrative synthesis of the outcomes of subgroup comparisons. Results. Sixteen systematic reviews were appraised. Overall, the methodological quality was low and external validity weak. For acute LBP, evidence that acupuncture has a more favorable effect than sham acupuncture in relieving pain was inconsistent; it had a similar effect on improving function. For chronic LBP, evidence consistently demonstrated that acupuncture provides short-term clinically relevant benefits for pain relief and functional improvement compared with no treatment or acupuncture plus another conventional intervention. Conclusion. Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

Does the addition of visceral manipulation alter outcomes for patients with low back pain? A randomized placebo controlled trial

BACKGROUND

This study aimed to investigate whether the addition of visceral manipulation, to a standard physiotherapy algorithm, improved outcomes in patients with low back pain.

METHODS

Sixty-four patients with low back pain who presented for treatment at a private physiotherapy clinic were randomized to one of two groups: standard physiotherapy plus visceral manipulation (n = 32) or standard physiotherapy plus placebo visceral manipulation (n = 32). The primary outcome was pain (measured with the 0-10 Numerical Pain Rating Scale) at 6 weeks. Secondary outcomes were pain at 2 and 52 weeks, disability (measured with the Roland-Morris Disability Questionnaire) at 2, 6 and 52 weeks and function (measured with the Patient-Specific Functional Scale) at 2, 6 and 52 weeks. This trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12611000757910).

RESULTS

The addition of visceral manipulation did not affect the primary outcome of pain at 6 weeks (-0.12, 95% CI = -1.45 to 1.21). There were no significant between-group differences for the secondary outcomes of pain at 2 weeks or disability and function at 2, 6 or 52 weeks. The group receiving addition of visceral manipulation had less pain than the placebo group at 52 weeks (mean 1.57, 95% CI = 0.32 to 2.82). Participants were adequately blinded to group status and there were no adverse effects reported in either group.

CONCLUSIONS

Our study suggests that visceral manipulation in addition to standard care is not effective in changing short-term outcomes but may produce clinically worthwhile improvements in pain at 1 year.

Randomized controlled trial of interpersonal psychotherapy versus enhanced treatment as usual for women with co-occurring depression and pelvic pain

OBJECTIVE

Our study assessed the effectiveness of Interpersonal Psychotherapy (IPT) tailored for biomedical patients with depression and pain. IPT was compared to enhanced treatment as usual (E-TAU) among women with co-occurring depression and chronic pain presenting for care at a women's health or family medicine practice. We hypothesized that women presenting to urban medical practices with depression and chronic pain would benefit from IPT tailored to address their needs to a greater degree than from E-TAU.

METHODS

We conducted a randomized controlled psychotherapy trial of 61 women from 2 urban medical practices who met criteria for major depressive disorder and chronic pelvic pain. Participants were assigned to receive either 8 sessions of IPT or a facilitated psychotherapy referral to a community mental health center, and assessed for depression, social interactions, and pain at 0-, 12-, 24-, and 36-weeks, with score on the Hamilton Rating Scale for Depression as the primary outcome. Both intent-to-treat (ITT) and causal modeling analyses correcting for treatment attendance were conducted.

RESULTS

ITT analyses were not significant. In causal modeling analyses, participants assigned to IPT showed significantly more improvement for depression and social interactions, but not for pain.

CONCLUSION

IPT may be a viable option as part of a comprehensive treatment program for women in medical practices with depression and chronic pain.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, NCT00895999.

Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

PURPOSE

The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems.

METHODS

A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors.

RESULTS

Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain.

CONCLUSIONS

No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly. Implications for Rehabilitation It remains challenging to correctly predict the outcome of treatment from patients' baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome. Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation. Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning. Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program. Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

The optimal frequency of aquatic physiotherapy for individuals with chronic musculoskeletal pain: a randomised controlled trial

PURPOSE

To establish whether there was a difference in health-related quality of life (HRQoL) in people with chronic musculoskeletal disorders (PwCMSKD) after participating in a multimodal physiotherapy program (MPP) either two or three sessions a week.

METHODS

Total of 114 PwCMSKD participated in this prospective randomised controlled trial. An individualised MPP, consisting of exercises for mobility, motor-control, muscle strengthening, cardiovascular training, and health education, was implemented either twice a week (G2: n = 58) or three times a week) (G3: n = 56) for 1 year.

OUTCOMES

HRQoL physical and mental health state (PHS/MHS), Roland Morris disability Questionnaire (RMQ), Neck-Disability-Index (NDI) and Western Ontario and McMaster Universities' Arthritis Index (WOMAC) were used to measure outcomes of MPP for people with chronic low back pain, chronic neck pain and osteoarthritis, respectively. Measures were taken at baseline, 8 weeks (8 w), 6 months (6 m), and 1 year (1 y) after starting the programme.

RESULTS

No statistically significant differences were found between the two groups (G2 and G3), except in NDI at 8 w (-3.34, (CI 95%: -6.94/0.84, p = 0.025 (scale 0-50)). All variables showed improvement reaching the following values (from baseline to 1 y) G2: PHS: 57.72 (baseline: 41.17; (improvement: 16.55%), MHS: 74.51 (baseline: 47.46, 27.05%), HRQoL 0.90 (baseline: 0.72, 18%)), HRQoL-VAS 84.29 (baseline: 58.04, 26.25%), RMQ 4.15 (baseline: 7.85, 15.42%), NDI 3.96 (baseline: 21.87, 35.82%), WOMAC 7.17 (baseline: 25.51, 19.10%). G3: PHS: 58.64 (baseline: 39.75, 18.89%), MHS: 75.50 (baseline: 45.45, (30.05%), HRQoL 0.67 (baseline: 0.88, 21%), HRQoL-VAS 86.91 (baseline: 52.64, 34.27%), RMQ 4.83 (baseline: 8.93, 17.08%), NDI 4.91 (baseline: 23.82, 37.82%), WOMAC 6.35 (baseline: 15.30, 9.32%).

CONCLUSIONS

No significant differences between the two groups were found in the outcomes of a MPP except in the NDI at 8 weeks, but both groups improved in all variables during the course of 1 year under study. Implications for Rehabilitation A multimodal physiotherapy program (MPP) improves quality of life, overall health, and function in people with chronic musculoskeletal disease after an intervention of short, medium and long term. This implies that twice a week MPP for people with chronic musculoskeletal pain has comparable results to three times a week provision and therefore may have implications in saving resources and cost for patients and service providers without compromising the outcomes of treatment. These results can be considered not only for therapists, but also for managers who offer the services to optimise the balance cost-effectiveness of the proposed interventions.

Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial

Background

Among the multiple conservative modalities, physiotherapy is a commonly utilized treatment modality in managing chronic non-specific spinal pain. Despite the scientific progresses with regard to pain and motor control neuroscience, treatment of chronic spinal pain (CSP) often tends to stick to a peripheral biomechanical model, without targeting brain mechanisms. With a view to enhance clinical efficacy of existing physiotherapeutic treatments for CSP, the development of clinical strategies targeted at ‘training the brain’ is to be pursued. Promising proof-of-principle results have been reported for the effectiveness of a modern neuroscience approach to CSP when compared to usual care, but confirmation is required in a larger, multi-center trial with appropriate evidence-based control intervention and long-term follow-up.

The aim of this study is to assess the effectiveness of a modern neuroscience approach, compared to usual care evidence-based physiotherapy, for reducing pain and improving functioning in patients with CSP. A secondary objective entails examining the effectiveness of the modern neuroscience approach versus usual care physiotherapy for normalizing brain gray matter in patients with CSP.

Methods/Design

The study is a multi-center, triple-blind, two-arm (1:1) randomized clinical trial with 1-year follow-up. 120 CSP patients will be randomly allocated to either the experimental (receiving pain neuroscience education followed by cognition-targeted motor control training) or the control group (receiving usual care physiotherapy), each comprising of 3 months treatment. The main outcome measures are pain (including symptoms and indices of central sensitization) and self-reported disability. Secondary outcome measures include brain gray matter structure, motor control, muscle properties, and psychosocial correlates. Clinical assessment and brain imaging will be performed at baseline, post-treatment and at 1-year follow-up. Web-based questionnaires will be completed at baseline, after the first 3 treatment sessions, post-treatment, and at 6 and 12-months follow-up.

Discussion

Findings may provide empirical evidence on: (1) the effectiveness of a modern neuroscience approach to CSP for reducing pain and improving functioning, (2) the effectiveness of a modern neuroscience approach for normalizing brain gray matter in CSP patients, and (3) factors associated with therapy success. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities’ recommendations.

Trial registration

ClinicalTrials.gov Identifier: NCT02098005.

Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study

BACKGROUND

Physical therapy influences chronic pain by means of the specific ingredient of an intervention as well as contextual factors including the setting and therapeutic alliance (TA) between provider and patient.

OBJECTIVE

The purpose of this study was to compare the effect of enhanced versus limited TA on pain intensity and muscle pain sensitivity in patients with chronic low back pain (CLBP) receiving either active or sham interferential current therapy (IFC).

DESIGN

An experimental controlled study with repeated measures was conducted. Participants were randomly divided into 4 groups: (1) AL (n=30), which included the application of active IFC combined with a limited TA; (2) SL (n=29), which received sham IFC combined with a limited TA; (3) AE (n=29), which received active IFC combined with an enhanced TA; and (4) SE (n=29), which received sham IFC combined with an enhanced TA.

METHODS

One hundred seventeen individuals with CLBP received a single session of active or sham IFC. Measurements included pain intensity as assessed with a numerical rating scale (PI-NRS) and muscle pain sensitivity as assessed via pressure pain threshold (PPT).

RESULTS

Mean differences on the PI-NRS were 1.83 cm (95% CI=14.3-20.3), 1.03 cm (95% CI=6.6-12.7), 3.13 cm (95% CI=27.2-33.3), and 2.22 cm (95% CI=18.9-25.0) for the AL, SL, AE, and SE groups, respectively. Mean differences on PPTs were 1.2 kg (95% CI=0.7-1.6), 0.3 kg (95% CI=0.2-0.8), 2.0 kg (95% CI=1.6-2.5), and 1.7 kg (95% CI=1.3-2.1), for the AL, SL, AE, and SE groups, respectively.

LIMITATIONS

The study protocol aimed to test the immediate effect of the TA within a clinical laboratory setting.

CONCLUSIONS

The context in which physical therapy interventions are offered has the potential to dramatically improve therapeutic effects. Enhanced TA combined with active IFC appears to lead to clinically meaningful improvements in outcomes when treating patients with CLBP.

Do manual therapies help low back pain? A comparative effectiveness meta-analysis

STUDY DESIGN

Meta-analysis methodology was extended to derive comparative effectiveness information on spinal manipulation for low back pain.

OBJECTIVE

Determine relative effectiveness of spinal manipulation therapies (SMTs), medical management, physical therapies, and exercise for acute and chronic nonsurgical low back pain.

SUMMARY OF BACKGROUND DATA

Results of spinal manipulation treatments of nonsurgical low back pain are equivocal. Nearly 40 years of SMT studies were not informative.

METHODS

Studies were chosen on the basis of inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated nonspecific from treatment effects. Aggregate data were tested for evidential support as compared with shams.

RESULTS

Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham's effectiveness. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not.

CONCLUSION

Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority matched a binomial random process. Treatments serve to motivate, reassure, and calibrate patient expectations--features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

Exercises for treatment of nonspecific low back pain

BACKGROUND AND OBJECTIVES

Low back pain is a common syndrome that causes disability and absence from work. Although there are several causes, the most common type of back pain is nonspecific. Exercises are often used to treat back pain, but there is controversy regarding its effectiveness. The aim of this paper is to review exercises for nonspecific low back pain treatment.

CONTENT

This paper provides a definition and classification of back pain. Incidence and mechanisms of nonspecific low back pain and exercises used for its treatment are hereby reported.

CONCLUSION

The most effective types of exercise therapy for chronic or acute low back pain are still controversial; however, exercise therapy is probably the most widely used conservative treatment throughout the world.

The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies

Background

Evidence suggests that the course of low back pain (LBP) symptoms in randomised clinical trials (RCTs) follows a pattern of large improvement regardless of the type of treatment. A similar pattern was independently observed in observational studies. However, there is an assumption that the clinical course of symptoms is particularly influenced in RCTs by mere participation in the trials. To test this assumption, the aim of our study was to compare the course of LBP in RCTs and observational studies.

Methods

Source of studies CENTRAL database for RCTs and MEDLINE, CINAHL, EMBASE and hand search of systematic reviews for cohort studies. Studies include individuals aged 18 or over, and concern non-specific LBP. Trials had to concern primary care treatments. Data were extracted on pain intensity. Meta-regression analysis was used to compare the pooled within-group change in pain in RCTs with that in cohort studies calculated as the standardised mean change (SMC).

Results

70 RCTs and 19 cohort studies were included, out of 1134 and 653 identified respectively. LBP symptoms followed a similar course in RCTs and cohort studies: a rapid improvement in the first 6 weeks followed by a smaller further improvement until 52 weeks. There was no statistically significant difference in pooled SMC between RCTs and cohort studies at any time point:- 6 weeks: RCTs: SMC 1.0 (95% CI 0.9 to 1.0) and cohorts 1.2 (0.7to 1.7); 13 weeks: RCTs 1.2 (1.1 to 1.3) and cohorts 1.0 (0.8 to 1.3); 27 weeks: RCTs 1.1 (1.0 to 1.2) and cohorts 1.2 (0.8 to 1.7); 52 weeks: RCTs 0.9 (0.8 to 1.0) and cohorts 1.1 (0.8 to 1.6).

Conclusions

The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. In addition to a shared ‘natural history’, enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design.

Self-reported moderate-to-vigorous leisure time physical activity predicts less pain and disability over 12 months in chronic and persistent low back pain

BACKGROUND

Physical deconditioning in combination with societal and emotional factors has been hypothesized to compromise complete recovery from low back pain (LBP). However, there is a lack of longitudinal studies designed to specifically investigate physical activity as an independent prognostic factor. We conducted a prognostic study to investigate whether levels of leisure time physical activity are independently associated with clinical outcomes in people seeking care for chronic and persistent LBP.

METHODS

A total of 815 consecutive patients presenting with LBP to an outpatient spine centre in secondary care were recruited. Separate multivariate linear regression analyses were performed to investigate whether levels of leisure time physical activity (i.e., sedentary, light and moderate-to-vigorous leisure time physical activity levels) predict pain and disability at 12-month follow-up, after adjusting for age, pain, episode duration, disability, neurological symptoms, depression and fear of movement.

RESULTS

Final models showed evidence of an association between baseline physical activity and 12-month outcomes (p < 0.001). In both models, the moderate-to-vigorous physical activity group reported less pain and disability compared with the sedentary group.

CONCLUSIONS

Our findings suggest that physical activity levels may have a role in the prognosis of LBP. Specific domains of physical activity warrant further investigation to better understand this association.

The addition of manipulation to an extension-oriented intervention for a patient with chronic LBP

OBJECTIVE AND IMPORTANCE

There is a paucity of research investigating the combined interventions of direction-specific lumbar exercise and manipulation for individuals with low back pain (LBP) who exhibit centralization or a directional preference. The purpose of this report was to describe the management and outcomes of a patient with chronic LBP who met two categories of the revised treatment based classification (TBC) approach initially described by Delitto and colleagues.

CLINICAL PRESENTATION

A 55-year-old female with a 15-year history of right LBP/leg pain demonstrated centralization of symptoms with repeated extension and met four out of five criteria on the clinical prediction rule for thrust manipulation.

INTERVENTIONS

The patient was treated for seven physical therapy sessions, once a week for seven weeks. Lumbar thrust manipulation and extension-oriented interventions were combined throughout the course of care. The patient experienced a decrease on the modified Oswestry disability index score from 26 to 8%, an increase in the patient-specific functional scale score from 5.6 to 9.4, and patient-report of full return to pain-free activity at discharge.

CONCLUSION

A patient with chronic LBP reported a clinically meaningful improvement after seven visits of manipulation and extension-oriented interventions. Further research should compare the effectiveness of combining interventions for individuals who meet the two TBC groups of manipulation and extension-specific exercise compared with performing either intervention alone.

Spinal manipulative therapy-specific changes in pain sensitivity in individuals with low back pain (NCT01168999)

Spinal manipulative therapy (SMT) is effective for some individuals experiencing low back pain; however, the mechanisms are not established regarding the role of placebo. SMT is associated with changes in pain sensitivity, suggesting related altered central nervous system response or processing of afferent nociceptive input. Placebo is also associated with changes in pain sensitivity, and the efficacy of SMT for changes in pain sensitivity beyond placebo has not been adequately considered. We randomly assigned 110 participants with low back pain to receive SMT, placebo SMT, placebo SMT with the instructional set "The manual therapy technique you will receive has been shown to significantly reduce low back pain in some people," or no intervention. Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η(2) = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT. This study was registered at www.clinicaltrials.gov under the identifier NCT01168999.

PERSPECTIVE

The results of this study indicate attenuation of pain sensitivity is greater in response to SMT than the expectation of receiving an SMT. These findings suggest a potential mechanism of SMT related to lessening of central sensitization and may indicate a preclinical effect beyond the expectations of receiving SMT.