Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines

Patients' prior perceptions and expectations of the Enhanced Transtheoretical Model Intervention for chronic low back pain: A qualitative study

BACKGROUND

The Enhanced Transtheoretical Model Intervention (ETMI) is an approach for treating chronic low back pain (CLBP), which demonstrated clinical and cost-effectiveness outcomes. ETMI highlights reassurance, return to normal activities and encouragement of recreational physical activity. In order to optimally implement ETMI, it is important to gain an understanding of the expectations and perceptions of patients before they engage with the intervention.

OBJECTIVES

To explore CLBP patients' perceptions and expectations of the ETMI method prior to their first consultation with physiotherapist.

METHODS

Qualitative semi-structured interviews were conducted with 30 CLBP patients. The interviews were audio-recorded, transcribed, coded, and analysed thematically. Patients were first asked about their expectations of treatment, then they were asked to comment on the ETMI method.

RESULTS

Three main themes emerged from the interviews: (1) Patient's perceptions of LBP; (2) patient's expectations from current physiotherapy and (3) Patient's expectations from ETMI method. The patients' perceptions of back pain centred on biomechanical causal factors, a desire for diagnostic tests and beliefs that rest cures the pain. Their expectations from current physiotherapy included pain reduction, passive treatment, a structured exercise program and clear information about LBP. In reference to the ETMI method, patients expected pain reduction, practical tools to self-manage, and a combination of ETMI with passive treatment.

CONCLUSION

addressing issues around patient's perceptions and expectations of current physiotherapy and of the ETMI method, prior to their first consultation with physiotherapist, could be beneficial for understanding how to improve the ETMI implementation in the health care system.

The Prospective Prognostic Value of Biopsychosocial Indices of Sensitivity to Physical Activity Among People With Back Pain

OBJECTIVES

Many people living with musculoskeletal pain conditions experience a range of negative biopsychosocial responses to physical activity, referred to as increased sensitivity to physical activity (SPA), that may undermine successful rehabilitation. This exploratory study aims to provide the first prospective analysis of the potential prognostic value of 3 biopsychosocial indices of SPA in relation to rehabilitation outcomes. This study also aimed to shed light on the cross-sectional interrelationships between these 3 biopsychosocial indices of SPA.

MATERIALS AND METHODS

Adults with back pain were evaluated upon starting physical therapy and then again 3 months later. The initial testing session consisted of self-reported pain-related questionnaires and assessment of activity-related changes in pressure pain thresholds (SPA-Sensory), pain intensity ratings (SPA-Pain), and situational catastrophizing (SPA-Psych). The 3-month follow-up consisted of self-reported disability and pain questionnaires. Correlational and hierarchical linear regression analyses were conducted.

RESULTS

A total of 97 participants completed both the initial visit and 3-month follow-up. The SPA-Pain index and the SPA-Psych index were significantly intercorrelated, but neither were correlated with the SPA-Sensory index. The SPA-Sensory index was not correlated with outcomes. The SPA-Pain index was correlated only with cross-sectional disability and pain outcomes. The SPA-Psych index was the only SPA index significantly correlated with outcomes both cross-sectionally and at 3-month follow-up. After controlling for baseline pain/disability and pain catastrophizing, SPA-Psych was no longer a significant prognostic factor for pain, but remained a significant prognostic factor for disability at 3-month follow-up (β=0.272, t=2.674, P=0.008, R2 Δ=5.60%).

DISCUSSION

This study highlights the importance of conceptualizing and measuring SPA as a biopsychosocial (rather than unidimensional) construct and points toward the added prognostic value of this construct. Implications for future research and practice are discussed.

The advice given by physiotherapists to people with back pain in primary care

BACKGROUND

Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by clinicians to patients with back pain at their initial consultation.

METHODS

A secondary analysis was conducted with 25 audio-recordings and transcriptions of consultations between patients with back pain and physiotherapists in a primary care outpatients department. Using a Framework approach, the data were coded and analysed to identify the content of advice given and mode of delivery.

RESULTS

The mean duration of consultation was 38 min 59 s (range 26:21-53:16). Advice was given in 88% (n = 22/25) of consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to 'move your back' despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and using heat. Gaps were identified in the advice given, most notably there was a lack of specificity relating to the frequency and duration of recommended tasks and activities.

CONCLUSIONS

Advice and reassurance are integral to enabling people to self-manage their back pain. It is important to avoid contradictory and unhelpful messages. Despite its importance, little is known about the advice offered by clinicians during initial back pain consultations highlighting the need for guidance to be patient-centred and tailored.

Taking patients to the ice cream shop but telling them that they cannot have ice cream: a qualitative study of orthopaedic spine clinicians' perceptions of persistent low back pain consultations

OBJECTIVE

This study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings.

SETTING

Secondary care sector in the UK.

PARTICIPANTS

Semi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians' perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

Two meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients' expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues.

CONCLUSION

The findings highlight clinicians' perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients' needs in circumstances where surgery is not indicated.

Erector spinae plane block for chronic low back pain analgesia: A case series

BACKGROUND

Chronic low back pain (CLBP) is a frequent condition, poorly managed with conventional treatments. The ultrasound-guided erector spinae plane block has increasingly been used in the management of acute and chronic pain. We aimed to determine this technique's analgesic efficacy in patients with moderate to severe CLBP.

METHODS

Ten consecutively selected patients: adults, regularly followed in our Pain Clinic with moderate/severe long-term CLBP refractory to pharmacological treatment, VAS > 4. Prospective data collection: before the intervention -demographical data, past medical history, current pain therapies, VAS pain level, Brief Pain Inventory- Short Form and Neuropathic Pain Questionnaire; 30 min after - VAS and satisfaction level; 24 and 72 h, 7 days and 1 month after - complications and pain level.

RESULTS

Majority of females (90%), mean age of 70.3 years-old. All had primary musculoskeletal CLBP. 90% experienced severe pain (VAS >= 7) in the last 24 h. Half presented neuropathic characteristics. Patients were very satisfied with the technique (mean: 8.75) with immediate pain relief (VAS mean: 2.3). 24 and 72 h, 7 days and 1 month after the treatment VAS means were 3.2, 3.1, 3.8 and 6.2. We report a 20.8 days duration mean. No short or long-term complications.

DISCUSSION AND CONCLUSIONS

Ultrasound-guided erector spinae plane block has preliminary advantages in CLBP: easily performed with low complications risk, immediate discharge home with absence of motor block, 100% efficacy at short and medium-terms. Even though pain's relief was shorter than a month, it is a useful tool allowing patients' well-being, physical rehabilitation and exercise during this period.

Acute effects of proprioceptive neuromuscular facilitation exercises on the postural strategy in patients with chronic low back pain

INTRODUCTION

Active treatments focused on improvement in motor function are postulated in chronic low back patients (CLBP).

OBJECTIVE

to establish the acute effects of PNF exercise on the postural control strategy.

METHODS

The sway of the body was tested before intervention in fifty-three CLBP patients and after that participants were randomly assigned into the intervention PNF group (n = 25). Mean velocity (VEL) and sample entropy (SEn), over the center of pressure in the mediolateral (ML) and anterior-posterior (AP) planes served to estimate the postural strategy and automaticity levels in the neuromuscular controller. Tandem and one-leg standing tests (OLST) with eyes open and eyes closed were used.

RESULTS

Pain intensity decreased after the intervention. The VEL was no longer vision-dependent in both planes. The SEn decreased immediately after the exercise and either returned to or even exceeded the baseline values in the OLST ML plane.

CONCLUSION

A single session of PNF exercise may have a beneficial effect on pain and postural control in CLBP patients. The statistically significant pain relief combined with newly acquired better control of posture may have encouraged the PNF group participants to a subconscious exploration of the stability area. Postural movements were more automatized in OLST in the delayed test.

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

Background

Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness.

Methods

We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool.

Results

We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources.

Conclusions

This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines.

Protocol Registation

PROSPERO CRD42017072518

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01136-w.

The effects of core stability training in nurses with nonspecific low back pain

To investigate the effect of core stability training on nonspecific low back pain (NSLBP) in nurses.The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires in our rehabilitation center. A total of 40 nurses with NSLBP were included and divided into observation group and control group. Each group were given routine health education for NSLBP. Core stability training was performed in observation group for 4 weeks. Surface electromyography (sEMG) evaluation of erector spine and multifidus muscle, pain Numeric Rating Scale (NRS) and Japanese Orthopaedic Association (JOA) scores were evaluated and analyzed before and 4 weeks after intervention.There was no significant difference of NRS score and JOA score between two groups before intervention (P > .05, respectively). The NRS and JOA scores were significantly improved in both two groups after 4 weeks of intervention (P < .05, respectively). Moreover, the improvement of NRS and JOA scores in the observation group were better than those of the control group (P < .05, respectively). No significant difference of average electromyography (AEMG) or median frequency (MF) were noted between the healthy side and the affected side in both groups before or after intervention (P > .05, respectively). After 4 weeks of intervention, the AEMG of the healthy and the affected side of the two groups showed an improved trend without significant difference (P > .05, respectively). The MF of affected side was significantly higher 4 weeks after intervention than those before treatment in the observation and control group (P < .05, respectively).Core stability training can alleviate pain, improve the fatigue resistance of the core muscles and the balance of the functions of bilateral multifidus muscles in nurses with NSLBP.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

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.

What is known about factors improving physiotherapists' adherence to high value interventions in nonspecific low back pain? A scoping review protocol

INTRODUCTION

Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high-value interventions in the management of non-specific LBP.

METHODS

This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand-searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non-specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics.

Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis

Objective

To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.

Design

A systematic review of the literature with network meta-analysis.

Data sources

Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.

Eligibility criteria for selecting studies

Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).

Results

Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) −1.40; 95% confidence interval (CI) −2.41 to –0.40), heat wrap (SMD −1.38; 95% CI −2.60 to –0.17), opioids (SMD −0.86; 95% CI −1.62 to –0.10), manual therapy (SMD −0.72; 95% CI −1.40 to –0.04) and non-steroidal anti-inflammatory drugs (NSAIDs) (SMD −0.53; 95% CI −0.97 to –0.09). Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.

Conclusion

With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance.

Effectiveness and Quality of Implementing a Best Practice Model of Care for Low Back Pain (BetterBack) Compared with Routine Care in Physiotherapy: A Hybrid Type 2 Trial

Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group—BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists’ care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 months and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.

The effectiveness of manual therapy and proprioceptive neuromuscular facilitation compared to kinesiotherapy: a four-arm randomized controlled trial

BACKGROUND

Low back pain (LBP) has a negative impact on patients' life, not only from the physical point of view, but also in terms of psychic, social and economic wellbeing. The increasing costs of treatment and health care encourage the search for the most effective methods of treatment.

AIM

The aim of the study was to determine whether the use of combined therapy consisting of manual therapy and proprioceptive neuromuscular facilitation (PNF) is more effective than the use of manual therapy techniques, PNF or traditional kinesiotherapy as single methods in the treatment of LBP.

DESIGN

A four-arm RCT.

SETTING

Rehabilitation Department of Hospital in Parczew (Poland).

METHODS

The study was designed as four-arm randomized comparative controlled RCT and conducted on a group of 200 patients aged 27-55y. (44.9±9.2 years). The patients were randomly divided into four 50-person groups: 1) group A - manual therapy; 2) B - PNF; 3) C - manual therapy and PNF; and 4) group D - traditional kinesiotherapy and control group. Pain intensity was measured using VAS and Laitinen's questionnaire. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS).

RESULTS

There was a statistically significant difference in pain reduction (VAS Scale) between Group C (4.8 points) and Group D (3.9 points). In all the groups there was a statistically significant reduction in a degree of disability as measured by the ODI. A level of functional capabilities (BPFS) increased significantly only in Group C (8.8 points) as compared to Group D (5.7 points).

CONCLUSIONS

All the evaluated methods caused pain reduction which lasted for at least 2 weeks after the end of treatment. The degree of disability as measured by ODI lowered evenly in all groups. Patients' functional ability assessed with BPFS improved significantly in the group treated with combined therapy (manual therapy and PNF) as compared to the group of traditional kinesiotherapy.

CLINICAL REHABILITATION IMPACT

The therapy consisting of manual therapy and the PNF method seemed to be more effective than the traditional kinesitherapy in improving functioning of patients with non-specific low back pain.

What Mediates Treatment Effects in a Presurgery Physiotherapy Treatment in Surgical Candidates With Degenerative Lumbar Spine Disorders? A Mediation and Conditional Process Analysis of the PREPARE Randomized Controlled Trial

OBJECTIVES

Treatment guidelines recommend targeting both physical and psychological factors in interventions for degenerative lumbar spine disorders. Studying the treatment mechanisms gives information on key factors explaining the outcome improvement that can refine treatments. This study explores treatment mediators in a physiotherapy treatment on disability, pain intensity, and health-related quality of life in surgical candidates with degenerative lumbar spine disorders compared with waiting-list controls. An additional aim was to evaluate patients' expectation as a moderator of treatment outcome.

MATERIALS AND METHODS

Data collected from 197 patients in a single-blinded randomized controlled trial comparing 9 weeks of multifaceted physiotherapy with waiting-list controls were used in this conditional process analysis. Analysis was carried out on group differences for change in Oswestry Disability Index, Pain Visual Analog Scale (VAS) back pain, EuroQol-5D, and EuroQol-VAS. The putative moderation role of expectations and mediation role of change in physical variables and psychosocial variables were tested.

RESULTS

Change in self-efficacy mediated improvement in all outcomes. Improvement in Oswestry Disability Index was also mediated by change in depression; VAS was mediated by change in fear-avoidance beliefs; and EuroQol-VAS was mediated by change in activity level and fear avoidance beliefs. Improvements were moderated by patients' treatment expectations.

DISCUSSION

Self-efficacy, fear-avoidance beliefs, physical activity level, and patients' treatment expectations were found to be important factors explaining treatment effects. Self-efficacy was the consistent mediator for effects of the presurgical physiotherapy on disability, back pain intensity, and health-related quality of life.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

Background

The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.

Methods

A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O’Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.

Results

In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.

Conclusion

We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04031-z.

Association between patient independence in performing an exercise program and adherence to home exercise program in people with chronic low back pain

BACKGROUND

A high percentage of patients with chronic low back pain (LBP) do not adequately adhere to home exercise programs. There is no information regarding a possible association between patient independence in performing an exercise program and adherence to this exercise program.

OBJECTIVE

To assess a possible association between patient independence in performing two different home exercise programs (treatment based on the Movement System Impairment-Based classification model (MSI) and treatment based on stretching and strengthening exercises for chronic LBP and adherence to those exercise programs.

DESIGN

This was a secondary analysis of a randomized controlled trial.

METHODS

The physical therapist assessed the patient's independence in performing the exercise program at the initial physical therapy sessions. Adherence was calculated during the 8-week treatment by the number of days performing the home exercise programs. Multivariate linear regression models were built to investigate whether patient independence in performing the home exercise program was associated with adherence to home exercise program for each treatment group adjusted for possible confounders (age, physical activity status, pain duration, pain intensity and disability at baseline).

RESULTS

We observed a clinically important association between patient independence in performing the home exercise and adherence to a treatment based on the MSI model group (ß = -15.6 days, 95%CI = -24.5 to -6.7, R² = 16%, p = 0.001).

CONCLUSIONS

People with chronic LBP adhered more to a home exercise program based on the MSI model when they are more independent in performing the exercise program.

The Importance of Perceived Relevance: A Qualitative Evaluation of Patient's Perceptions of Value and Impact Following a Low-Intensity Group-Based Pain Management Program

Background and objectives: Limited evidence exists exploring perceptions of which aspects of a pain management program are perceived as valuable and impactful. The aim of this study was to explore patient beliefs about which aspects of a pain management program were valued and/or had perceived impact. Materials and Methods: One-on-one structured interviews were conducted with 11 adults three months after their completion of the Spark Pain Program at Westmead Hospital, Sydney, Australia. Concepts in the transcripts were inductively identified and explored, utilizing thematic analysis to better understand their relevance to the study aim. Results: Four themes emerged: (1) "The program overall was positive, but…"; (2) "I valued my improved knowledge and understanding of pain, but…"; (3) "I valued the stretching/relaxation/pacing/activity monitoring"; and (4) "I valued being part of a supportive and understanding group". Participants reported that they liked being treated as an individual within the group. A lack of perceived personal relevance of key messages was identified in some participants; it appears that patients in pain programs must determine that changes in knowledge, beliefs, and attitudes are personally relevant in order for the changes to have a significant impact on them. Conclusions: This study provides new insights into aspects of a pain management program that were perceived as valuable and impactful, areas that "missed the mark", and hypotheses to guide the implementation of service delivery and program redesign.

Experiences of training and delivery of Physical therapy informed by Acceptance and Commitment Therapy (PACT): a longitudinal qualitative study

OBJECTIVES

Physiotherapy informed by Acceptance and Commitment Therapy (PACT) is a novel intervention that is related to improved disability and functioning in people with chronic lowback pain. This study explored physiotherapists experiences over time of the PACT training programme and intervention delivery.

DESIGN

A longitudinal qualitative study using semi-structured, in-depth, individual interviews at three time points was conducted.

METHODS

A phenomenological approach underpinned the methods. Interviews followed topic-guides developed a priori. Transcribed interviews were coded inductively to generate themes. Data were member checked by participants and validated by two researchers.

PARTICIPANTS

Eight clinical physiotherapists from three secondary care centres in the United Kingdom (n = 5 female; age, 24 to 44 years; duration of practice, 3 to 14 years) were included.

RESULTS

Five themes emerged from the data. Experiential learning techniques were challenging but valued because they bridged theoretical principles and concepts with practice. Ongoing individual and group supervision was beneficial, but required tailoring and tapering. PACT delivery extended physiotherapy skills and practice, including techniques that acknowledged and addressed patient treatment expectations. With experience, participants desired greater flexibility and autonomy to tailor PACT delivery.

CONCLUSIONS

PACT training and delivery were acceptable to physiotherapists. Existing skills were developed and additional, applicable approaches were provided that addressed psychosocial and behavioural aspects of chronic low back pain.

Efficacy of abdominal trunk muscles-strengthening exercise using an innovative device in treating chronic low back pain: a controlled clinical trial

Exercise is the most common conservative intervention for chronic low back pain (CLBP). We have developed an innovative exercise device for the abdominal trunk muscles that also measures muscle strength in a sitting position. The device, which is easy for patients with CLBP to use, allows for lumbar stabilization exercise under pressure. This study aimed to examine the efficacy of abdominal trunk muscle strengthening using the device in improving CLBP. We conducted a two-group non-randomized controlled clinical trial. CLBP patients were allocated into two groups. The strengthening group underwent a 12-week exercise program that included abdominal trunk muscle strengthening using our device and stretching exercises, while the control group received a 12-week stretching exercise program. The outcome measures included the improvement of the abdominal trunk muscle strength measured by the device, pain intensity of CLBP, physical function, and quality of life (QOL). A total of 40 participants (20 in each group) were analyzed. The strengthening group showed better improvement in the abdominal trunk muscle strength, CLBP, physical function, and QOL than in the control group. In conclusion, the strengthening exercise using the device with easy stretching was effective in improving the strength of the abdominal trunk muscles, pain intensity of CLBP, physical function, and QOL.

Assessment of the Quality of Mobile Applications (Apps) for Management of Low Back Pain Using the Mobile App Rating Scale (MARS)

Digital health interventions may improve different behaviours. However, the rapid proliferation of technological solutions often does not allow for a correct assessment of the quality of the tools. This study aims to review and assess the quality of the available mobile applications (apps) related to interventions for low back pain. Two reviewers search the official stores of Android (Play Store) and iOS (App Store) for localisation in Spain and the United Kingdom, in September 2019, searching for apps related to interventions for low back pain. Seventeen apps finally are included. The quality of the apps is measured using the Mobile App Rating Scale (MARS). The scores of each section and the final score of the apps are retrieved and the mean and standard deviation obtained. The average quality ranges between 2.83 and 4.57 (mean 3.82) on a scale from 1 (inadequate) to 5 (excellent). The best scores are found in functionality (4.7), followed by aesthetic content (mean 4.1). Information (2.93) and engagement (3.58) are the worst rated items. Apps generally have good overall quality, especially in terms of functionality and aesthetics. Engagement and information should be improved in most of the apps. Moreover, scientific evidence is necessary to support the use of applied health tools.

Evaluating the impact of a champion on implementation of the Back Skills Training (BeST) programme in Canada: a mixed methods feasibility study protocol

INTRODUCTION

There is global recognition that low back pain (LBP) should be managed with a biopsychosocial approach. Previous implementation of this approach resulted in low uptake and highlighted the need for ongoing support. This study aims to explore the feasibility of (i) training and using a champion to support implementation, (ii) using a cluster randomised controlled trial (RCT), (iii) collecting patient reported outcome measures in a Canadian public healthcare setting and to identify contextual barriers to implementation.

METHODS

A pragmatic cluster RCT with embedded qualitative study with physiotherapists treating LBP in publicly funded physiotherapy departments in Newfoundland and Labrador, Canada. Participants will complete a previously developed online training course to equip them to deliver a biopsychosocial intervention for LBP. Clusters randomised to the intervention arm will receive additional support from a champion. A minimum champion training package has been developed based on known barriers in the literature. This includes strategies to target barriers relating to group-based scheduling issues, lack of managerial support, perceived patient factors such as addressing patient expectations for other types of treatments or selecting which patients might be best suited for this intervention, and anxiety about delivering something new. This package will be further codeveloped with study champions based on identified implementation barriers using the Behaviour Change Wheel. Clusters will be monitored for 6 months to assess champion and physiotherapist recruitment and retention, acceptability and implementation of the champion training, and the viability of conducting a cluster RCT in this setting. A purposive sample of physiotherapists will be interviewed from both arms.

ETHICS AND DISSEMINATION

This study was approved by Newfoundland and Labrador Health Research Ethics Authority in December 2018. Results will be disseminated to academic audiences through conferences and peer reviewed publications; to all study participants, their clinical leads, and patients with LBP.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04377529; Memorial University of Newfoundland Protocol Record 20190025; Pre-results.

Relevance of a novel external dynamic distraction device for treating back pain

Low back pain is a common, expensive, and disabling condition in industrialized countries. There is still no consensus for its ideal management. Believing in the beneficial effect of traction, we developed a novel external dynamic distraction device. The purpose of this work was to demonstrate that external distraction allows limiting the pressure exerted in standing-up position on the lower intervertebral discs. Numerical and cadaveric studies were used as complementary approaches. Firstly, we implemented the device into a numerical model of a validated musculoskeletal software (Anybody Modeling System) and we calculated the lower disc pressure while traction forces were applied. Secondly, we performed an anatomical study using a non-formalin preserved cadaver placed in a sitting position. A pressure sensor was placed in the lower discs under fluoroscopic control through a Jamshidi needle. The intradiscal pressure was then measured continuously at rest while applying a traction force of 200 N. Both numerical and cadaveric studies demonstrated a decrease in intradiscal pressures after applying a traction force with the external device. Using the numerical model, we showed that tensile forces below 500 N in total were sufficient. The application of higher forces seems useless and potentially deleterious. External dynamic distraction device is able to significantly decrease the intradiscal pressure in a sitting or standing position. However, the therapeutic effects need to be proven using clinical studies.

Are clinical practice guidelines for low back pain interventions of high quality and updated? A systematic review using the AGREE II instrument

BACKGROUND

Clinical practice guidelines (CPGs) provide recommendations for practice, but the proliferation of CPGs issued by multiple organisations in recent years has raised concern about their quality. The aim of this study was to systematically appraise CPGs quality for low back pain (LBP) interventions and to explore inter-rater reliability (IRR) between quality appraisers. The time between systematic review search and publication of CPGs was recorded.

METHODS

Electronic databases (PubMed, Embase, PEDro, TRIP), guideline organisation databases, websites, and grey literature were searched from January 2016 to January 2020 to identify GPCs on rehabilitative, pharmacological or surgical intervention for LBP management. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool to evaluate CPGs quality and record the year the CPGs were published and the year the search strategies were conducted.

RESULTS

A total of 21 CPGs met the inclusion criteria and were appraised. Seven (33%) were broad in scope and involved surgery, rehabilitation or pharmacological intervention. The score for each AGREE II item was: Editorial Independence (median 67%, interquartile range [IQR] 31-84%), Scope and Purpose (median 64%, IQR 22-83%), Rigour of Development (median 50%, IQR 21-72%), Clarity and Presentation (median 50%, IQR 28-79%), Stakeholder Involvement (median 36%, IQR 10-74%), and Applicability (median 11%, IQR 0-46%). The IRR between the assessors was nearly perfect (interclass correlation 0.90; 95% confidence interval 0.88-0.91). The median time span was 2 years (range, 1-4), however, 38% of the CPGs did not report the coverage dates for systematic searches.

CONCLUSIONS

We found methodological limitations that affect CPGs quality. In our opinion, a universal database is needed in which guidelines can be registered and recommendations dynamically developed through a living systematic reviews approach to ensure that guidelines are based on updated evidence.

LEVEL OF EVIDENCE

1 TRIAL REGISTRATION: REGISTRATION PROSPERO DETAILS: CRD42019127619 .

Efficacy and tolerability of orally administered tramadol/dexketoprofen fixed-dose combination compared to diclofenac/thiocolchicoside in acute low back pain: experience from an Italian, single-centre, observational study

OBJECTIVES

To compare the analgesic efficacy and tolerability of tramadol/dexketoprofen 75/25 mg (TRAM/DKP) versus diclofenac/thiocolchicoside 75/4 mg (DIC/THIO) in patients with moderate-to-severe acute low back pain (LBP).

METHODS

Single-centre, observational study in 82 adult outpatients with LBP due to disc herniation (≥4 Numerical Rating scale, NRS) who received either oral TRAM/DKP (n = 44) or intramuscular DIC/THIO (n = 38), both given every 12 h for 5 days. The primary endpoint was the change from baseline in pain intensity (PI) at pre-specified post-dose time points (t day1, t day3, t day7) and compared between the two treatments. Additional endpoints, all evaluated at day 7, included: the sum of PI difference (SPID), percentage of responders in terms of PI reduction versus baseline and change from baseline in Douleur Neuropathique (DN4) score. Tolerability and safety were also assessed.

RESULTS

Both treatment groups were comparable for demographic characteristics and comorbidities. Over the 5-day treatment period and up to day 7, compared to DIC/THIO, TRAM/DKP provided a significantly greater and sustained analgesia at day 3 and day 7 (p < .0001), with a higher proportion of responders at each time point [75% versus 71.1% (p = 0.687) at day 1, 93.2% versus 73.7% at day 3 (p = .016) and 95.5% versus 71.1% at day 7 (p = .003)], higher values of SPID (770.9 ± 23.5 vs. 507.1 ± 22.6; p < .0001) and significantly greater reduction in DN4 score [-62.7 ± 25.6 vs. -39.7 ± 31.2 (p < .0001)]. Both treatments were well tolerated.

CONCLUSIONS

Orally administered TRAM/DKP 75/25 mg can be a valuable and effective option in patients with acute LBP.

Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety

Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

The role of the pharmacist in low back pain management: a narrative review of practice guidelines on paracetamol vs non-steroidal anti-inflammatory drugs

Low back pain (LBP) is a common and costly condition and a leading cause of disabilities across the globe. In Australia and other countries, there has been changes in LBP management guidelines and evidence in recent years, including the use of pharmacotherapy. Inadequately treated LBP is a burden with significant health and economic impacts. Although there is some variability, non-steroidal anti-inflammatory drugs (NSAIDs) have largely replaced paracetamol as the first-choice analgesic for non-specific LBP in many international clinical guidelines, including the current Australian Therapeutic Guidelines. More recent clinical evidence also supports that targeting LBP with the use of NSAIDs can provide superior and more effective relief of LBP symptoms compared with paracetamol. Community pharmacists are one of the most accessible and frequently visited health professionals that offer vital primary healthcare services aimed to provide enhanced clinical outcomes for patients. The position of a community pharmacist is pivotal in LBP assessment and management, from both a pharmacological and non-pharmacological standpoint, including the use of clinical guidelines, yet their roles are often not fully utilized in LBP therapy. Studies investigating the community pharmacist’s views, practices, knowledge, and roles, specifically in LBP management in Australia are variable and limited. This narrative review will briefly cover the impacts of LBP, and to provide a summary on recent evidence, updates and a comparison of the Australian and international low back pain management guidelines on paracetamol vs NSAIDs in LBP, as well as pharmacists’ roles and interventions in a primary healthcare setting in this context.

Does early physical therapy intervention reduce opioid burden and improve functionality in the management of chronic lower back pain?

Introduction

Chronic lower back pain is a leading cause of disability in US adults. Opioid use continues to be controversial despite the Centers for Disease Control and Prevention guidance on chronic pain management to use nonpharmacologic and nonopioid pharmacologic interventions. The objectives of the study were to assess the impact of early physical therapy (PT) intervention on improving functionality and reducing opioid burden in patients with chronic lower back pain.

Methods

A single-center, retrospective chart review of patients receiving ≥6 PT visits and treated with either opioids first (OF) or PT first (PTF) therapy for chronic lower back pain were evaluated. Concomitant use of nonopioid and nonpharmacologic therapy was permitted. The Oswestry Disability Index (ODI), a survey measuring functionality, was recorded for PTF group. Pain scores and medication use including opioids were collected at treatment initiation and completion.

Results

One hundred and eighty patients were included in three groups: OF group (n = 60), PTF group (n = 60), and PTF + ODI group (n = 60). The PTF + ODI group had mean ODI reduction of 11.9% (P < .001). More OF patients were lost to follow up (68.3%) or failed PT (60%) compared to the PTF group, 38.3% and 3.3% (P < .001). Reduction in both opioid and nonopioid medications as well as pain scores were observed but not statistically significant.

Discussion

Early PT resulted in improved functionality, decreased pain, and reduced medication use upon PT completion. These findings suggest PT, along with nonopioid modalities, are a viable first-line option for the management of chronic lower back pain.

Static and Dynamic Balance in Adults Undergoing Lumbar Spine Surgery: Screening and Prediction of Postsurgical Outcomes

INTRODUCTION

Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes.

METHODS

Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery.

RESULTS

From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance.

DISCUSSION

Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.

Baseline characteristics did not identify people with low back pain who respond best to a Movement System Impairment-Based classification treatment

STUDY DESIGN

Secondary analysis of data from a randomized controlled trial.

BACKGROUND

Treatment based on the Movement System Impairment-Based classification for chronic low back pain results in the same benefit when compared to other forms of exercise. It is possible that participant's characteristics measured at baseline can identify people with chronic low back pain who would respond best to a treatment based on the Movement System Impairment model.

OBJECTIVES

To assess if specific characteristics of people with chronic low back pain measured at baseline can modify the effects of a treatment based on the Movement System Impairment model on pain and disability.

METHODS

Four variables assessed at baseline that could potentially modify the treatment effects of the treatment based on the Movement System Impairment model were selected (age, educational status, physical activity status and STarT back tool classification). Separate univariate models were used to investigate a possible modifier treatment effect of baseline participant's characteristics on pain and disability after the treatment. Findings of interaction values above 1 point for the outcome mean pain intensity or above 3 points for disability (Roland Morris questionnaire) were considered clinically relevant.

RESULTS

Linear regression analyses for the outcomes of pain and disability did not show interaction values considered clinically relevant for age, educational status, physical activity status and STarT back tool classification.

CONCLUSION

Age, educational status, physical activity status and STarT back tool classification did not modify the effects of an 8-week treatment based on the Movement System Impairment model in patients with chronic low back pain. Registered at www.clinicaltrials.gov: NCT02221609 (https://clinicaltrials.gov/ct2/show/NCT02221609).

Comparison of efficacy of a supervised versus non-supervised physical therapy exercise program on the pain, functionality and quality of life of patients with non-specific chronic low-back pain: a randomized controlled trial

OBJECTIVE

To compare the effectiveness of supervised physical therapy program versus non-supervised on pain, functionality, fear of movement and quality of life in patients with non-specific chronic low back pain.

DESIGN

A randomized double-blind clinical trial.

SETTING

Clinical outpatient unit; home.

SUBJECTS

A total of 64 participants with non-specific chronic low back pain were randomized into either supervised exercise group (n = 32) or non-supervised home exercise group (n = 32).

INTERVENTIONS

The supervised group was treated with therapy exercises (strengthen lumbopelvic musculature), while the non-supervised received an informative session of the exercises, which were performed un-supervised at home. Both groups received three weekly sessions for eight weeks.

MAIN MEASURES

Pain, disability, fear of movement, quality of life, trunk muscle endurance and trunk anteflexion motion were assessed at baseline, two, and six months of follow-up.

RESULTS

Although analysis of variance (ANOVA) test showed statistically significant differences between groups for pain (P = 0.028; supervised: 2.5 ± 2.1; non-supervised: 3.5 ± 1.5) and disability for Roland-Morris Disability Questionnaire (P = 0.004; supervised: 3.1 ± 2.2; non-supervised: 5.1 ± 3.0) and for Oswestry Disability Index (P = 0.034; supervised: 14.5 ± 7.1; non-supervised: 19.2 ± 10.0) at 8 weeks immediately posttreatment, there were no differences between the groups in patient-rated pain, functionality, fear of movement and quality of life at six months of follow-up.

CONCLUSION

Patients with chronic low back pain who received supervised exercise showed more improvement in both the short and long term in all patient-rated outcomes over the non-supervised group, but the differences were small and not clinically significant.

Efficacy and safety of duloxetine in osteoarthritis or chronic low back pain: a Systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of duloxetine in the treatment of patients with osteoarthritis (OA) or chronic low back pain (CLBP).

METHODS

Relevant randomized controlled trials (RCTs) were searched in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Included RCTs compared the efficacy and safety of duloxetine vs placebo in the treatment of OA or CLBP. Weighted mean difference (WMD) were calculated for continuous outcomes while risk ratio (RR) were calculated for dichotomous outcomes.

RESULTS

Nine RCTs were included in our meta-analysis. Duloxetine had significant improvement over placebo in Brief Pain Inventory 24-h average pain [WMD: -0.67; 95% confidence interval (CI):-0.80, -0.53], weekly mean of the 24-h average pain (WMD: -0.65; 95% CI: -0.79, -0.52), Patient's Global Impression of Improvement (WMD: -0.41; 95% CI: -0.49, -0.32), Clinical Global Impression of Severity (WMD: -0.32; 95% CI: -0.38, -0.25), European Quality of Life Questionnaire-5 Dimension (WMD: 0.04; 95% CI: 0.02, 0.07). In addition, duloxetine is associated with more treatment-emergent adverse events (TEAEs) (RR: 1.25; 95% CI: 1.17, 1.33) and discontinuations for adverse events (AEs) (RR: 2.31; 95% CI: 1.81, 2.94). However, there was no statistically significant difference in serious AEs between duloxetine and placebo.

CONCLUSION

Duloxetine had modest to moderate effects on pain relief, function improvement, mood regulation and improvement in quality of life with mild AEs in the treatment of OA or CLBP. Future RCTs should focus on comparing duloxetine with other oral drugs and assessing the long-term safety of duloxetine.

Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care

BACKGROUND

Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´ confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists.

METHODS

This clinical trial was an experimental before and after study within a hybrid type 2 effectiveness-implementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons.

RESULTS

One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (ηp2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (ηp2 = 0.071, p < 0.01) and lower biomedical orientation, (ηp2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

CONCLUSIONS

Physiotherapists´ confidence and biopsychosocial orientation increased after implementation and may have the potential to improve management of low back pain in primary care. The implementation behaviour showed mostly facilitating patterns but changed over time, pinpointing a need to repeatedly monitor these changes. This can inform the need for changes of implementation efforts in different phases and support sustainability strategies.

TRAIL REGISTRATION

ClinicalTrials.gov NCT03147300 3 May 2017, prospectivly registered.

Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an "implementation to innovation" system

Objectives: Many barriers exist to delivering high-value care for people with low back pain (LBP). We have developed a multistrategy implementation system to overcome these barriers. Here we describe a qualitative evaluation of the experiences of private-sector physiotherapists implementing the system.

Design: PRISM (Practice-based innovation and implementation system) is an iterative clinician-as-scientist implementation program, tailored here for acute and subacute LBP. PRISM integrates strategies from behavioral change, implementation, and educational science fields. Semistructured interviews, group discussion forums, and electronic questionnaires were used to collect data at multiple time points that were then analyzed using an interpretative descriptive approach.

Participants: Six physiotherapists (purposive sample) practicing in private practice physiotherapy clinics in the Adelaide region, South Australia, were enrolled in the study.

Interventions: Interventions included an educational pain science and care workshop incorporating self-regulated learning principles, a co-planned clinical pathway, an electronic decision support tool, development and support of a community of practice, case study simulations, audit and feedback, and collaborative problem solving and innovation for physiotherapists.

Results: Participants’ experiences and perceptions centered around five themes: (1) knowledge and skills training; (2) networking and mentoring; (3) a clear clinical pathway; (4) practical tools; and (5) data feedback. Participants appraised the implementation process positively but identified patient receptiveness as a challenge at times. Suggestions for improvement included streamlining/automating data collection forms and processes and providing more simulation opportunities.

Conclusions: PRISM appears to be a promising approach to overcoming several barriers that prevent people with back pain from receiving high-value care. It consolidates and increases pain science knowledge and increases physiotherapist confidence in delivering high-value care. It appears to legitimize some current practices, enhance clinical reasoning and communication skills, extend knowledge in line with contemporary pain science, and facilitate the application of a biopsychosocial management approach. The high-level acceptance by participants provides a foundation for further research to test outcomes and delivery in different settings.

Contribution of the article

A quality improvement intervention designed to improve delivery of high-value care was well received by private practice physiotherapists.

Physiotherapists particularly valued using experiential learning to improve fluency in communicating with, and educating patients about, contemporary pain science.

A structured clinical pathway and tools guided physiotherapists on the basic elements of necessary care and allowed them to concentrate on higher levels of decision making and communication with patients.

Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study

Background

Emergency department based Physical Therapy (ED-PT) has been practiced globally in various forms for over 20 years and is an emerging resource in the US. While there is a growing body of evidence suggesting that ED-PT has a positive effect on a number of clinical and operational outcomes in patients presenting with musculoskeletal (MSK) pain, there are few published narratives that quantify this in the US. Although there are international papers that offer outcome data on reduction of pain, imaging, throughput time, and the ability of physical therapists to appropriately manage MSK conditions in the ED setting, most papers to date have been descriptive in nature. The purpose of this study is to assess the impact of ED-PT on imaging studies obtained, rates of opioids prescribed, and ED length of stay.

Methods

We prospectively identified patients presenting with musculoskeletal pain to an urban academic ED in Salt Lake City between January 2017 and June 2018. During the study, a physical therapist was in the ED three days (24 hours) per week and was available to evaluate and treat patients after consultation by the ED provider. We noted patient demographic information, imaging performed in the ED, medications administered and prescribed, and ED length of stay. We classified patients as those who received PT in the ED and those who did not and compared clinical outcomes between groups. We performed a subgroup analysis of patients presenting with low back pain and matched patients by age and gender.

Results

Over the 18-month study period, we identified 524 patients presenting to the ED with musculoskeletal pain. 381 (72.7%) received ED-initiated PT. The PT and non-PT groups were similar in average age (42.8 years vs. 45.1 years, p = 0.155), gender (% female: 53% vs. 46.9%, p-0.209), and primary presenting chief complaint (cervical, thoracic, or lumbar pain: 57.7% vs. 53.1%, p = 0.345). Patients who received PT had lower rates of imaging (38.3% vs. 51%, p = 0.009), ED opioid administration (17.5% vs. 32.9%, p<0.001), and a shorter average ED length of stay (4 hours vs. 6.2 hours, p<0.001). Rates of outpatient opioid prescriptions were similar between groups (16% vs. 21.7%, p = 0.129). In a subgroup analysis of patients presenting with low back pain, we found that PT patients had fewer imaging studies (PT 25% vs. non-PT 57%, p = 0.029) but found no difference in average ED length of stay (PT 3.7 hours vs. non-PT 4.6 hours, p = 0.21), opioid administration in the ED (PT 36% vs. non-PT 43%, P = 0.792), nor outpatient opioid administration (PT 17.9%. vs non-PT 17.9%, p = 1.0).

Conclusion

In our experience, being seen by a physical therapist for MSK pain within the ED was associated with reduced use of imaging and time spent in the ED. Patients seeing a Physical Therapist were also less likely to receive an opioid prescription within the ED, a potentially significant finding given the need for opioid reduction strategies.

Death of the ALARA Radiation Protection Principle as Used in the Medical Sector

ALARA is the acronym for "As Low As Reasonably Achievable." It is a radiation protection concept borne from the linear no-threshold (LNT) hypothesis. There are no valid data today supporting the use of LNT in the low-dose range, so dose as a surrogate for risk in radiological imaging is not appropriate, and therefore, the use of the ALARA concept is obsolete. Continued use of an outdated and erroneous principle unnecessarily constrains medical professionals attempting to deliver high-quality care to patients by leading to a reluctance by doctors to order images, a resistance from patients/parents to receive images, subquality images, repeated imaging, increased radiation exposures, the stifling of low-dose radiation research and treatment, and the propagation of radiophobia and continued endorsement of ALARA by regulatory bodies. All these factors result from the fear of radiogenic cancer, many years in the future, that will not occur. It has been established that the dose threshold for leukemia is higher than previously thought. A low-dose radiation exposure from medical imaging will likely upregulate the body's adaptive protection systems leading to the prevention of future cancers. The ALARA principle, as used as a radiation protection principle throughout medicine, is scientifically defunct and should be abandoned.

Operationalization of the new Pain and Disability Drivers Management model: A modified Delphi survey of multidisciplinary pain management experts

BACKGROUND

We recently proposed the Pain and Disability Drivers Management (PDDM) model, which was designed to outline comprehensive factors driving pain and disability in low back pain (LBP). Although we have hypothesized and proposed 41 elements, which make up the model's five domains, we have yet to assess the external validity of the PDDM's elements by expert consensus.

RESEARCH OBJECTIVES

This study aimed to reach consensus among experts regarding the different elements that should be included in each domain of the PDDM model.

RELEVANCE

The PDDM may assist clinicians and researchers in the delivery of targeted care and ultimately enhance treatment outcomes in LBP.

METHODS

Using a modified Delphi survey, a two-round online questionnaire was administered to a group of experts in musculoskeletal pain management. Participants were asked to rate the relevance of each element proposed within the model. Participants were also invited to add and rate new elements. Consensus was defined by a greater than or equal to 75% level of agreement.

RESULTS

A total of 47 (round 1) and 33 (round 2) participants completed the survey. Following the first round, 38 of 41 of the former model elements reached consensus, and 10 new elements were proposed and later rated in the second round. Following this second round, consensus was reached for all elements (10 new + 3 from first round), generating a final model composed of 51 elements.

CONCLUSION

This expert consensus-derived list of clinical elements related to the management of LBP represents a first step in the validation of the PDDM model.

Back rehabilitation - The 3R's approach

Exercise is vital to the management of low back pain (LBP). However, research, social media, and fitness industry interests can leave therapists confused about best practice in exercise prescription for this clinical condition. The 3R's approach to back rehabilitation is introduced as an evidence-based framework for developing patient specific exercise throughout the back-pain journey. Clinical guidelines for the management of LBP are presented, and both exercise and psychological considerations are overviewed. The contrast between biomedical and biopsychosocial models of healthcare is introduced in relation to LBP and the requirements of a successful rehabilitation programme. Interacting factors in LBP, red flags, and motor skill classification are considered. The concept of tissue capacity is introduced, and the healing timescale addressed. Both are used as a foundation for exercise choice and progression. Simple methods of structuring an exercise programme are drawn from the fitness industry and adapted for use in rehabilitation. The 3R's approach consists of 3 interrelated and overlapping phases - reactive, recovery, and resilience. Treatment aims for each are introduced with guidance given to indicate appropriate patient progression between phases. Exercise examples of each stage are illustrated with consideration given to clinical reasoning, teaching method, safety and effectiveness.

Predicting the duration of sickness absence spells due to back pain: a population-based study from Sweden

Objectives

We aimed to develop and validate a prediction model for the duration of sickness absence (SA) spells due to back pain (International Statistical Classification of Diseases and Related Health Problems 10th Revision: M54), using Swedish nationwide register microdata.

Methods

Information on all new SA spells >14 days from 1 January 2010 to 30 June 2012 and on possible predictors were obtained. The duration of SA was predicted by using piecewise constant hazard models. Nine predictors were selected for the final model based on a priori decision and log-likelihood loss. The final model was estimated in a random sample of 70% of the SA spells and later validated in the remaining 30%.

Results

Overall, 64 048 SA spells due to back pain were identified during the 2.5 years; 74% lasted ≤90 days, and 9% >365 days. The predictors included in the final model were age, sex, geographical region, employment status, multimorbidity, SA extent at the start of the spell, initiation of SA spell in primary healthcare and number of SA days and specialised outpatient healthcare visits from the preceding year. The overall c-statistic (0.547, 95% CI 0.542 to 0.552) suggested a low discriminatory capacity at the individual level. The c-statistic was 0.643 (95% CI 0.634 to 0.652) to predict >90 days spells, 0.686 (95% CI 0.676 to 0.697) to predict >180 spells and 0.753 (95% CI 0.740 to 0.766) to predict >365 days spells.

Conclusions

The model discriminates SA spells >365 days from shorter SA spells with good discriminatory accuracy.

VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain

DESCRIPTION

In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP).

METHODS

The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline.

RECOMMENDATIONS

The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.

Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial

BACKGROUND

Degenerative lumbar spine disorders are common among musculoskeletal disorders. When disabling pain and radiculopathy persists after adequate course of rehabilitation and imaging confirms compressive pathology, surgical decompression is indicated. Prehabilitation aiming to augment functional capacity pre-surgery may improve physical function and activity levels pre and post-surgery. This study aims to evaluate the effect and dose-response of pre-surgery physiotherapy on quadriceps femoris strength and walking ability in patients with degenerative lumbar spine disorders compared to waiting-list controls and their association with postoperative physical activity level.

METHOD

In this single blinded, 2-arm randomised controlled trial, 197 patients were consecutively recruited. Inclusion criteria were: MRI confirmed diagnosis and scheduled for surgery due to disc herniation, lumbar spinal stenosis, degenerative disc disease or spondylolisthesis, ages 25-80 years. Patients were randomised to 9 weeks of pre-surgery physiotherapy or to waiting-list. Patient reported physical activity level, walking ability according to Oswestry Disability Index item 4, walking distance according to the SWESPINE national register and physical outcome measures including the timed ten-meter walk test, maximum voluntary isometric quadriceps femoris muscle strength, patient-rated were collected at baseline and follow-up. Parametric or non-parametric within and between group comparisons as well as multivariate regression was performed.

RESULTS

Patients who received pre-surgery physiotherapy significantly improved in all variables from baseline to follow-up (p < 0.001 - p < 0.05) and in comparison to waiting-list controls (p < 0.001 - p < 0.028). Patients adhering to ≥12 treatment sessions significantly improved in all variables (p < 0.001 - p < 0.032) and those receiving 0-11 treatment session in only normal walking speed (p0.035) but there were no significant differences when comparing dosages. Physical outcome measures after pre-surgery physiotherapy together significantly explain 27.5% of the variation in physical activity level 1 year after surgery with pre-surgery physical activity level having a significant multivariate association.

CONCLUSION

Pre-surgery physiotherapy increased walking ability and lower extremity strength in patients with degenerative lumbar spine disorders compared to waiting-list controls. A clear treatment dose-response response relationship was not found. These results implicate that pre-surgery physiotherapy can influence functional capacity before surgical treatment and has moderate associations with maintained postoperative physical activity levels mostly explained by physical activity level pre-surgery.

TRIAL REGISTRATION

NCT02454400 . Trial registration date: August 31st 2015, retrospectively registered.

The Effects Of Myofascial Release Technique Combined With Core Stabilization Exercise In Elderly With Non-Specific Low Back Pain: A Randomized Controlled, Single-Blind Study

Purpose

To evaluate the effects of Myofascial Release Technique (MRT) with a roller massager combined with core stabilization exercises (CSE) in elderly with non-specific low back pain (NSLBP).

Patients and methods

A total of forty-five participants were randomly divided into two groups (CSE and CSE+MRT). A core stabilization exercise program was applied for the participants in the CSE group for 3 days per week for a total of 6 weeks. In addition to the core stabilization exercises, myofascial relaxation technique with a roller massager was performed for 3 days per week for 6 weeks for the participants in the CSE+MRT group. Participants were assessed in terms of pain, low back disability, lower body flexibility, kinesiophobia, core stability endurance, spinal mobility, gait characteristics and quality of life both pre- and post-treatment.

Results

It was found that the improvement in core stability endurance (p=0.031) and spinal mobility (in the sagittal plane) (p=0.022) was greater in the CSE+MRT group compared to the CSE group. There was no significant difference between the two groups in terms of pain, low back disability, lower body flexibility, kinesiophobia, gait characteristics and quality of life (p>0.05).

Conclusion

The current study suggests that myofascial release technique with a roller massager combined with core stabilization exercises can be a better choice in the treatment of NSLBP in elderly.

ClinicalTrials.gov Identifier

NCT03898089.

Cost-effectiveness analysis of the pharmacological management of chronic low back pain with four leading drugs

BACKGROUND

Chronic low back pain is a major health problem that has a substantial effect on people's quality of life and places a significant economic burden on healthcare systems. However, there has been little cost-effectiveness analysis of the treatments for it. Therefore, the purpose of this prospective observational study was to evaluate the cost-effectiveness of the pharmacological management of chronic low back pain.

METHODS

A total of 474 patients received pharmacological management for chronic low back pain using four leading drugs for 6 months at 28 institutions in Japan. Outcome measures, including EQ-5D, the Japanese Orthopaedic Association (JOA) score, the JOA back pain evaluation questionnaire (BPEQ), the Roland-Morris Disability Questionnaire, the Medical Outcomes Study SF-8, and the visual analog scale, were investigated at baseline and every one month thereafter. The incremental cost-utility ratio (ICUR) was calculated as drug cost over the quality-adjusted life years. An economic estimation was performed from the perspective of a public healthcare payer in Japan. Stratified analysis based on patient characteristics was also performed to explore the characteristics that affect cost-effectiveness.

RESULTS

The ICUR of pharmacological management for chronic low back pain was JPY 453,756. Stratified analysis based on patient characteristics suggested that the pharmacological treatments for patients with a history of spine surgery or cancer, low frequency of exercise, long disease period, low scores in lumbar spine dysfunction and gait disturbance of the JOA BPEQ, and low JOA score at baseline were not cost-effective.

CONCLUSIONS

Pharmacological management for chronic low back pain is cost-effective from the reference willingness to pay. Further optimization based on patient characteristics is expected to contribute to the sustainable development of a universal insurance system in Japan.

The contemporary management of nonspecific lower back pain

Low back pain (LBP) is extremely common and causes an enormous burden on the society. This perspective article aims to provide an evidence-based summary in the field of LBP. More specifically, we aimed to present epidemiological data on cost, diagnosis, prognosis, prevention and interventions for patients with LBP. It is critical that both clinicians and policymakers follow best practices by using high-value care for patients with LBP. In addition, nonevidence-based procedures must be immediately abandoned. These actions are likely to reduce societal costs and will improve the quality of life of these patients.

Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis

BACKGROUND

Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP.

METHODS/DESIGN

We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model.

DISCUSSION

Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018102527.

Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain

Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP management. Taking into account the scale and costs of CLBP, it is imperative that healthcare professionals have access to up-to-date, evidence-based information to assist them in treatment decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews, meta-analysis and available treatment guidelines, most physically inactive therapies should not be considered for CLBP management, except for pain neuroscience education and spinal manipulative therapy if combined with exercise therapy, with or without psychological therapy. Regarding active therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises should not be considered due to low-quality and/or conflicting evidence. Exercise interventions on the other hand are recommended, but while all exercise modalities appear effective compared to minimal/passive/conservative/no intervention, there is no evidence that some specific types of exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient’s preferences and abilities. When exercise interventions are combined with a psychological component, effects are better and maintain longer over time.