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Matsudaira K, Oka H, Kikuchi N, Haga Y, Sawada T, Tanaka S. Psychometric Properties of the Japanese Version of the STarT Back Tool in Patients with Low Back Pain. PLoS One 2016; 11:e0152019. [PMID: 27002823 PMCID: PMC4803233 DOI: 10.1371/journal.pone.0152019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/08/2016] [Indexed: 12/19/2022] Open
Abstract
Background and Objective The STarT Back Tool uses prognostic indicators to classify patients with low back pain into three risk groups to guide early secondary prevention in primary care. The present study aimed to evaluate the psychometric properties of the Japanese version of the tool (STarT-J). Methods An online survey was conducted among Japanese patients with low back pain aged 20–64 years. Reliability was assessed by examining the internal consistency of the overall and psychosocial subscales using Cronbach’s alpha coefficients. Spearman’s correlation coefficients were used to evaluate the concurrent validity between the STarT-J total score/psychosocial subscore and standard reference questionnaires. Discriminant validity was evaluated by calculating the area under the curves (AUCs) for the total and psychosocial subscale scores against standard reference cases. Known-groups validity was assessed by examining the relationship between low back pain-related disability and STarT-J scores. Results The analysis included data for 2000 Japanese patients with low back pain; the mean (standard deviation [SD]) age was 47.7 (9.3) years, and 54.1% were male. The mean (SD) STarT-J score was 2.2 (2.1). The Cronbach’s alpha coefficient was 0.75 for the overall scale and 0.66 for the psychosocial subscale. Spearman’s correlation coefficients ranged from 0.30 to 0.59, demonstrating moderate to strong concurrent validity. The AUCs for the total score ranged from 0.65 to 0.83, mostly demonstrating acceptable discriminative ability. For known-groups validity, participants with more somatic symptoms had higher total scores. Those in higher STarT-J risk groups had experienced more low back pain-related absences. Conclusions The overall STarT-J scale was internally consistent and had acceptable concurrent, discriminant, and known-groups validity. The STarT-J can be used with Japanese patients with low back pain.
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Affiliation(s)
- Ko Matsudaira
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- * E-mail:
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Norimasa Kikuchi
- Clinical Study Support, Inc., Nagoya, Aichi, Japan
- Department of Public Health, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Yuri Haga
- Clinical Study Support, Inc., Nagoya, Aichi, Japan
| | - Takayuki Sawada
- Clinical Study Support, Inc., Nagoya, Aichi, Japan
- Department of Public Health, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Abbott A. Evidence base and future research directions in the management of low back pain. World J Orthop 2016; 7:156-161. [PMID: 27004162 PMCID: PMC4794533 DOI: 10.5312/wjo.v7.i3.156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/17/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
Low back pain (LBP) is a prevalent and costly condition. Awareness of valid and reliable patient history taking, physical examination and clinical testing is important for diagnostic accuracy. Stratified care which targets treatment to patient subgroups based on key characteristics is reliant upon accurate diagnostics. Models of stratified care that can potentially improve treatment effects include prognostic risk profiling for persistent LBP, likely response to specific treatment based on clinical prediction models or suspected underlying causal mechanisms. The focus of this editorial is to highlight current research status and future directions for LBP diagnostics and stratified care.
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Goode AP, Coeytaux RR, McDuffie J, Duan-Porter W, Sharma P, Mennella H, Nagi A, Williams JW. An evidence map of yoga for low back pain. Complement Ther Med 2016; 25:170-7. [PMID: 27062965 DOI: 10.1016/j.ctim.2016.02.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 12/21/2015] [Accepted: 02/26/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Yoga is being increasingly studied as a treatment strategy for a variety of different clinical conditions, including low back pain (LBP). We set out to conduct an evidence map of yoga for the treatment, prevention and recurrence of acute or chronic low back pain (cLBP). METHODS We searched Medline, Cochrane Database of Systematic Reviews, EMBASE, Allied and Complementary Medicine Database and ClinicalTrials.gov for randomized controlled trials (RCT), systematic reviews or planned studies on the treatment or prevention of acute back pain or cLBP. Two independent reviewers screened papers for inclusion, extracted data and assessed the quality of included studies. RESULTS Three eligible systematic reviews were identified that included 10 RCTs (n=956) that evaluated yoga for non-specific cLBP. We did not identify additional RCTs beyond those included in the systematic reviews. Our search of ClinicalTrials.gov identified one small (n=10) unpublished trial and one large (n=320) planned clinical trial. The most recent good quality systematic review indicated significant effects for short- and long-term pain reduction (n=6 trials; standardized mean difference [SMD] -0.48; 95% CI, -0.65 to -0.31; I(2)=0% and n=5; SMD -0.33; 95% CI, -0.59 to -0.07; I(2)=48%, respectively). Long-term effects for back specific disability were also identified (n=5; SMD -0.35; 95% CI, -0.55 to -0.15; I(2)=20%). No studies were identified evaluating yoga for prevention or treatment of acute LBP. CONCLUSION Evidence suggests benefit of yoga in midlife adults with non-specific cLBP for short- and long-term pain and back-specific disability, but the effects of yoga for health-related quality of life, well- being and acute LBP are uncertain. Without additional studies, further systematic reviews are unlikely to be informative.
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Affiliation(s)
- Adam P Goode
- Department of Orthopedic Surgery, Duke University Medical Center, 2200 West Main Street, Durham, NC 27705, United States; Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, United States.
| | - Remy R Coeytaux
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, United States.
| | - Jennifer McDuffie
- Durham Center for Health Services Research in Primary Care and Evidence Synthesis Program, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, United States; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, United States.
| | - Wei Duan-Porter
- Durham Center for Health Services Research in Primary Care and Evidence Synthesis Program, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, United States; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, United States.
| | - Poonam Sharma
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, United States.
| | - Hillary Mennella
- Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710, United States.
| | - Avishek Nagi
- Durham Center for Health Services Research in Primary Care and Evidence Synthesis Program, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, United States.
| | - John W Williams
- Durham Center for Health Services Research in Primary Care and Evidence Synthesis Program, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, United States; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, United States.
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Karstens S, Krug K, Hill JC, Stock C, Steinhaeuser J, Szecsenyi J, Joos S. Validation of the German version of the STarT-Back Tool (STarT-G): a cohort study with patients from primary care practices. BMC Musculoskelet Disord 2015; 16:346. [PMID: 26559635 PMCID: PMC4642614 DOI: 10.1186/s12891-015-0806-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/05/2015] [Indexed: 12/19/2022] Open
Abstract
Background Current research emphasizes the high prevalence and costs of low back pain (LBP). The STarT Back Tool was designed to support primary care decision making for treatment by helping to determine the treatment prognosis of patients with non-specific low back pain. The German version is the STarT-G. The cross-cultural translation of the tool followed a structured and widely accepted process but to date it was only partially validated with a small sample. The aim of the study was to test the psychometric properties construct validity, discriminative ability, internal consistency and test-retest-reliability of the STarT-G and to compare them with values given for the original English version. Methods A consecutive cohort study with a two-week retest was conducted among patients with non-specific LBP, aged 18 to 60 years, from primary care practices. Questionnaires were collected before the first consultation, and two weeks later by post, using the following reference standards: the Roland and Morris disability questionnaire, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale. Psychometric properties examined included the tool’s discriminative abilities, whether the psychosocial subscale was one factor, internal consistency, item redundancy, test-retest reliability and floor and ceiling effects. Results There were 228 patients recruited with a mean age of 42.2 (SD 11.0) years, and 53 % were female. The areas under the curve (AUC) for discriminative ability ranged from 0.70 (STarT-G Subscale - Pain Catastrophizing Scale; CI95 0.63, 0.78) to 0.77 (STarT-G Total - Composite reference standard, CI95 0.60, 0.94). Factor loadings ranged from 0.49 to 0.74. Cronbach’s alpha testing the internal consistency and redundancy for the total/subscale scores were α = 0.52/0.55 respectively. The STarT-G test-retest reliability Kappa values for the total/subscale scores were 0.67/0.68 respectively. No floor or ceiling effects were present. Conclusions The STarT-G shows acceptable psychometric properties although not in exact agreement with the original English version. The items previously regarded as a psychosocial subscale may be better seen as an index of different individual psychosocial constructs. The relevance of using the tool at the point of consultation should be further examined.
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Affiliation(s)
- Sven Karstens
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
| | - Katja Krug
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Jonathan C Hill
- Institute of Primary Care and Health Sciences, Keele University, Keele/Stoke-on-Trent, United Kingdom
| | - Christian Stock
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Jost Steinhaeuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein Campus Luebeck, Luebeck, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefanie Joos
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.,Institute for General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany
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Karstens S, Joos S, Hill JC, Krug K, Szecsenyi J, Steinhäuser J. General Practitioners Views of Implementing a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study. PLoS One 2015; 10:e0136119. [PMID: 26322985 PMCID: PMC4554726 DOI: 10.1371/journal.pone.0136119] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 07/29/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP). METHODS A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach. RESULTS For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues. CONCLUSIONS The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by involvement of specifically trained medical assistants.
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Affiliation(s)
- Sven Karstens
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Stefanie Joos
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Jonathan C. Hill
- Institute of Primary Care and Health Sciences, Keele University, Keele/Stoke-on-Trent, United Kingdom
| | - Katja Krug
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Jost Steinhäuser
- Institute of Family medicine, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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Pagé I, Abboud J, O Shaughnessy J, Laurencelle L, Descarreaux M. Chronic low back pain clinical outcomes present higher associations with the STarT Back Screening Tool than with physiologic measures: a 12-month cohort study. BMC Musculoskelet Disord 2015; 16:201. [PMID: 26286385 PMCID: PMC4541753 DOI: 10.1186/s12891-015-0669-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stratification strategies based on identifying patient's prognosis in order to guide patient care constitute one of the most prominent and recent approach in low back pain research. The STarT Back Screening Tool (SBST) although promising, has not been studied in patients with chronic low back pain (cLBP). Considering how challenging it is to translate research into practice, the value of integrating a new tool should be thoroughly assessed. The purpose was therefore to assess associations between the short- and long-terms clinical status and two types of variables, physiologic measures and the SBST, in participants with cLBP. The ability of both types of variables to discriminate between participants with and without higher levels of disability, pain, fear of movement and patient's global impression of change was also investigated. METHODS Fifty-three volunteers with cLBP participated in an initial evaluation and follow-ups at 2-, 4-, 6- and 12-month. Physiologic measures (maximal voluntary contraction, maximal endurance and muscle activity evaluated during prone and lateral isometric tasks) and the SBST were assessed at baseline. Disability (Oswestry Disability Index, ODI), pain intensity (101-point Numerical Rating Scale, NRS), fear of movement (Tampa Scale for Kinesiophobia, TSK) and patient's global impression of change (7-point scale, PGIC) were evaluated at baseline and at each follow-up. Aside the use of correlation analyses to assess potential associations; ROC curves were performed to evaluate the discriminative ability of physiologic measures and the SBST. RESULTS The SBST allowed for the identification of participants presenting higher levels of disability (ODI ≥24 %), pain (NRS ≥37 %) or fear of movement (TSK ≥41/68) over a 12-month period (AUC = 0.71 to 0.84, ps < 0.05). The SBST score was also correlated with disability at each follow-up (τ = 0.22 to 0.33, ps < 0.05) and with pain intensity and fear of movement at follow-ups. Among physiologic measures, only maximal voluntary contraction was correlated to disability, pain intensity or fear of movement during the follow-up (|τ| = 0.26 to 0.32, ps < 0.05) and none was able to identify participants presenting higher levels of outcomes (AUC ps > 0.05). CONCLUSION Physiologic measures obtained during prone and lateral tests have limited associations with the clinical status over a 12-month period in patients with nonspecific chronic low back pain. On the other hand, the STarT Back Screening Tool is useful for the identification of patients who will present higher levels of disability, pain intensity and fear of movement over a year. TRIAL REGISTRATION Clinicaltrials.gov NCT02226692.
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Affiliation(s)
- Isabelle Pagé
- Département des sciences de l'activité physique, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, Québec, Canada.
| | - Jacques Abboud
- Département d'anatomie, UQTR, Trois-Rivières, Québec, Canada.
| | - Julie O Shaughnessy
- Département de chiropratique, UQTR, Trois-Rivières, Québec, Canada. Julie.O'
| | - Louis Laurencelle
- Département des sciences de l'activité physique, UQTR, Trois-Rivières, Québec, Canada.
| | - Martin Descarreaux
- Département des sciences de l'activité physique, Université du Québec à Trois-Rivières, 3351 Boul. Des Forges, Trois-Rivières, G9A 5H7, Québec, Canada.
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Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study. Phys Ther 2015; 95:1120-34. [PMID: 25858972 PMCID: PMC4528015 DOI: 10.2522/ptj.20140418] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 04/02/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effectiveness of risk stratification for low back pain (LBP) management has not been demonstrated in outpatient physical therapy settings. OBJECTIVE The purposes of this study were: (1) to assess implementation of a stratified care approach for LBP management by evaluating short-term treatment effects and (2) to determine feasibility of conducting a larger-scale study. DESIGN This was a 2-phase, preliminary study. METHODS In phase 1, clinicians were randomly assigned to receive standard (n=6) or stratified care (n=6) training. Stratified care training included 8 hours of content focusing on psychologically informed practice. Changes in LBP attitudes and beliefs were assessed using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). In phase 2, clinicians receiving the stratified care training were instructed to incorporate those strategies in their practice and 4-week patient outcomes were collected using a numerical pain rating scale (NPRS), and the Oswestry Disability Index (ODI). Study feasibility was assessed to identify potential barriers for completion of a larger-scale study. RESULTS In phase 1, minimal changes were observed for PABS-PT and HC-PAIRS scores for standard care clinicians (Cohen d=0.00-0.28). Decreased biomedical (-4.5±2.5 points, d=1.08) and increased biopsychosocial (+5.5±2.0 points, d=2.86) treatment orientations were observed for stratified care clinicians, with these changes sustained 6 months later on the PABS-PT. In phase 2, patients receiving stratified care (n=67) had greater between-group improvements in NPRS (0.8 points; 95% confidence interval=0.1, 1.5; d=0.40) and ODI (8.9% points; 95% confidence interval=4.1, 13.6; d=0.76) scores compared with patients receiving standard physical therapy care (n=33). LIMITATIONS In phase 2, treatment was not randomly assigned, and therapist adherence to treatment recommendations was not monitored. This study was not adequately powered to conduct subgroup analyses. CONCLUSIONS In physical therapy settings, biomedical orientation can be modified, and risk-stratified care for LBP can be effectively implemented. Findings from this study can be used for planning of larger studies.
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108
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Using the STarT Back Tool: Does timing of stratification matter? ACTA ACUST UNITED AC 2015; 20:533-9. [DOI: 10.1016/j.math.2014.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 07/25/2014] [Accepted: 08/01/2014] [Indexed: 11/18/2022]
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Hidalgo B, Pitance L, Hall T, Detrembleur C, Nielens H. Short-Term Effects of Mulligan Mobilization With Movement on Pain, Disability, and Kinematic Spinal Movements in Patients With Nonspecific Low Back Pain: A Randomized Placebo-Controlled Trial. J Manipulative Physiol Ther 2015. [DOI: 10.1016/j.jmpt.2015.06.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Schaafsma FG, Anema JR, van der Beek AJ. Back pain: Prevention and management in the workplace. Best Pract Res Clin Rheumatol 2015; 29:483-94. [PMID: 26612243 DOI: 10.1016/j.berh.2015.04.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite all the efforts in studying work-related risk factors for low back pain (LBP), interventions targeting these risk factors to prevent LBP have no proven cost-effectiveness. Even with adequate implementation strategies for these interventions on group level, these did not result in the reduction of incident LBP. Physical exercise, however, does have a primary preventive effect on LBP. For secondary prevention, it seems that there are more opportunities to cost-effectively intervene in reducing the risk of long-term sickness absence due to LBP. Starting at the earliest moment possible with proper assessment of risk factors for long-term sickness absence related to the individual, the underlying mechanisms of the LBP, and also factors related to the workplace by a well-trained clinician, may increase the potential of effective return to work (RTW) management. More research on how to overcome barriers in the uptake of these effective interventions in relation to policy-specific environments, and with regard to proper financing of RTW management is necessary.
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Affiliation(s)
- Frederieke G Schaafsma
- Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Research Centre for Insurance Medicine, Collaboration Between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands.
| | - Johannes R Anema
- Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Research Centre for Insurance Medicine, Collaboration Between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Allard J van der Beek
- Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Research Centre for Insurance Medicine, Collaboration Between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands; Body@Work, Research Center Physical Activity, Work and Health, TNO-VU University Medical Center, Amsterdam, The Netherlands
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111
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Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther 2015; 95:791-800. [PMID: 25504491 DOI: 10.2522/ptj.20140156] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 11/25/2014] [Indexed: 11/17/2022]
Abstract
Shoulder disorders are a common musculoskeletal problem causing pain and functional loss. Traditionally, diagnostic categories are based on a pathoanatomic medical model aimed at identifying the pathologic tissues. However, the pathoanatomic model may not provide diagnostic categories that effectively guide treatment decision making in rehabilitation. An expanded classification system is proposed that includes the pathoanatomic diagnosis and a rehabilitation classification based on tissue irritability and identified impairments. For the rehabilitation classification, 3 levels of irritability are proposed and defined, with corresponding strategies guiding intensity of treatment based on the physical stress theory. Common impairments are identified and are used to guide specific intervention tactics with varying levels of intensity. The proposed system is conceptual and needs to be tested for reliability and validity. This classification system may be useful clinically for guiding rehabilitation intervention and provides a potential method of identifying relevant subgroups in future research studies. Although the system was developed for and applied to shoulder disorders, it may be applicable to classification and rehabilitation of musculoskeletal disorders in other body regions.
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112
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Morso L, Kongsted A, Hestbaek L, Kent P. The prognostic ability of the STarT Back Tool was affected by episode duration. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:936-44. [PMID: 25835771 DOI: 10.1007/s00586-015-3915-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/26/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The prognostic ability of the STarT Back Tool (SBT) reportedly varies, but the factors affecting this are unclear. This study investigated the influences of care setting (chiropractic, GP, physiotherapy, spine centre), episode duration (0-2, 3-4, 4-12, >12 weeks), and outcome time period (3, 6, 12 months) on SBT prognostic ability. METHODS This was a secondary analysis of data from three primary care cohorts [chiropractic (n = 416), GP (n = 265), and physiotherapy (n = 200) practices] and one cohort from a secondary care outpatient spine centre (n = 974) in Denmark. Care pathways were not systematically affected by SBT risk subgroup (non-stratified care). Using generalised estimating equations, we investigated statistical interactions between SBT risk subgroups and potentially influential factors on the prognostic ability of the SBT subgroups, when Roland Morris Disability Questionnaire scores were the outcome. RESULTS SBT risk subgroup, age, care setting, and episode duration were all independent prognostic factors. The only investigated factor that modified the prognostic ability of the SBT subgroups was episode duration. CONCLUSIONS These results indicate that the prognostic ability of the SBT in these non-stratified care settings was unaffected by care setting on its own. However, the prognosis of patients is affected by diverse clinical characteristics that differ between patient populations, many of which are not assessed by the SBT. When controlling for some of those factors and testing potential interactions, the results showed that only episode duration affected the SBT prognostic ability and, specifically, that the SBT was less predictive in very acute patients (<2 weeks duration).
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Affiliation(s)
- Lars Morso
- Centre for Quality, Region of Southern Denmark, P.V. Tuxensvej 5, 5500, Middelfart, Denmark.
| | - Alice Kongsted
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Lise Hestbaek
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Peter Kent
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study. Spine (Phila Pa 1976) 2015; 40:405-14. [PMID: 25599287 DOI: 10.1097/brs.0000000000000770] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Within-study cost-utility analysis. OBJECTIVE To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain). SUMMARY OF BACKGROUND DATA Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up. METHODS Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence. RESULTS Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively). CONCLUSION At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only. LEVEL OF EVIDENCE 2.
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Haskins R, Osmotherly PG, Southgate E, Rivett DA. Australian physiotherapists’ priorities for the development of clinical prediction rules for low back pain: A qualitative study. Physiotherapy 2015; 101:44-9. [DOI: 10.1016/j.physio.2014.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
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Haskins R, Osmotherly PG, Rivett DA. Validation and impact analysis of prognostic clinical prediction rules for low back pain is needed: a systematic review. J Clin Epidemiol 2015; 68:821-32. [PMID: 25804336 DOI: 10.1016/j.jclinepi.2015.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 01/05/2015] [Accepted: 02/09/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To identify prognostic forms of clinical prediction rules (CPRs) related to the nonsurgical management of adults with low back pain (LBP) and to evaluate their current stage of development. STUDY DESIGN AND SETTING Systematic review using a sensitive search strategy across seven databases with hand searching and citation tracking. RESULTS A total of 10,005 records were screened for eligibility with 35 studies included in the review. The included studies report on the development of 30 prognostic LBP CPRs. Most of the identified CPRs are in their initial phase of development. Three CPRs were found to have undergone validation--the Cassandra rule for predicting long-term significant functional limitations and the five-item and two-item Flynn manipulation CPRs for predicting a favorable functional prognosis in patients being treated with lumbopelvic manipulation. No studies were identified that investigated whether the implementation of a CPR resulted in beneficial patient outcomes or improved resource efficiencies. CONCLUSION Most of the identified prognostic CPRs for LBP are in the initial phase of development and are consequently not recommended for direct application in clinical practice at this time. The body of evidence provides emergent confidence in the limited predictive performance of the Cassandra rule and the five-item Flynn manipulation CPR in comparable clinical settings and patient populations.
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Affiliation(s)
- Robin Haskins
- School of Health Sciences, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia.
| | - Peter G Osmotherly
- School of Health Sciences, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia
| | - Darren A Rivett
- School of Health Sciences, University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia
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Transcultural adaption and psychometric properties of the STarT Back Screening Tool among Finnish low back pain patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:287-295. [DOI: 10.1007/s00586-015-3804-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/06/2015] [Accepted: 02/06/2015] [Indexed: 11/26/2022]
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Diagnostic clinical prediction rules for specific subtypes of low back pain: a systematic review. J Orthop Sports Phys Ther 2015; 45:61-76, A1-4. [PMID: 25573009 DOI: 10.2519/jospt.2015.5723] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To identify diagnostic clinical prediction rules (CPRs) for low back pain (LBP) and to assess their readiness for clinical application. BACKGROUND Significant research has been invested into the development of CPRs that may assist in the meaningful subgrouping of patients with LBP. To date, very little is known about diagnostic forms of CPRs for LBP, which relate to the present status or classification of an individual, and whether they have been developed sufficiently to enable their application in clinical practice. METHODS A sensitive electronic search strategy using 7 databases was combined with hand searching and citation tracking to identify eligible studies. Two independent reviewers identified relevant studies for inclusion using a 2-stage selection process. The quality appraisal of included studies was conducted by 2 independent raters using the Quality Assessment of Diagnostic Accuracy Studies-2 and checklists composed of accepted methodological standards for the development of CPRs. RESULTS Of 10 014 studies screened for eligibility, the search identified that 13 diagnostic CPRs for LBP have been derived. Among those, 1 tool for identifying lumbar spinal stenosis and 2 tools for identifying inflammatory back pain have undergone validation. No impact analysis studies were identified. CONCLUSION Most diagnostic CPRs for LBP are in their initial development phase and cannot be recommended for use in clinical practice at this time. Validation and impact analysis of the diagnostic CPRs identified in this review are warranted, particularly for those tools that meet an identified unmet need of clinicians who manage patients with LBP. LEVEL OF EVIDENCE Diagnosis, level 2a-.
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Sheeran L, Coales P, Sparkes V. Clinical challenges of classification based targeted therapies for non-specific low back pain: What do physiotherapy practitioners and managers think? ACTA ACUST UNITED AC 2014; 20:456-62. [PMID: 25511448 PMCID: PMC4425945 DOI: 10.1016/j.math.2014.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/16/2014] [Accepted: 11/17/2014] [Indexed: 11/18/2022]
Abstract
Background Classification of non-specific low back pain (NSLBP) was recommended to better target care and so maximise treatment potential. This study investigated physiotherapy practitioners' (PPs) and managers' (PMs) views, experiences and perceptions of barriers and enablers for using classification systems (CSs) to better target treatment for NSLBP in the NHS primary care setting. Design Qualitative focus group and interviews. Methods Data from semi-structured interviews of three PMs and a focus group with five PPs, considered local opinion leaders in physiotherapy, was thematically analysed. Results Five themes emerged (i) CS knowledge: PPs and PMs were aware of CSs and agreed with its usefulness. PPs were mostly aware of CSs informing specific treatments whilst PMs were aware of prognosis based CSs. (ii) Using CSs: PPs classify by experience and clinical reasoning skills, shifting between multiple CSs. PMs were confident that evidence-based practice takes place but believed CSs may not be always used. (iii) Advantages/disadvantages of CSs: Effective targeting of treatments to patients was perceived as advantageous; but the amount of training required was perceived as disadvantageous. (iv) Barriers: Patients' expectations, clinicians' perceptions, insufficiently complex CSs, lack of training resources. (v) Enablers: Development of sufficiently complex CSs, placed within the clinical reasoning process, mentoring, positive engagement with stakeholders and patients. Conclusions PPs and PMs were aware of CSs and agreed with its usefulness. The current classification process was perceived to be largely influenced by individual practitioner knowledge and clinical reasoning skills rather than being based on one CS alone. Barriers and enablers were identified for future research.
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Affiliation(s)
- Liba Sheeran
- Cardiff University, School of Healthcare Sciences, Ty Dewi Sant, Heath Park, Cardiff, CF14 4XN, UK.
| | - Philippa Coales
- Cardiff University, School of Healthcare Sciences, Ty Dewi Sant, Heath Park, Cardiff, CF14 4XN, UK
| | - Valerie Sparkes
- Cardiff University, School of Healthcare Sciences, Ty Dewi Sant, Heath Park, Cardiff, CF14 4XN, UK
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Beneciuk JM, Robinson ME, George SZ. Subgrouping for patients with low back pain: a multidimensional approach incorporating cluster analysis and the STarT Back Screening Tool. THE JOURNAL OF PAIN 2014; 16:19-30. [PMID: 25451622 DOI: 10.1016/j.jpain.2014.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 10/02/2014] [Accepted: 10/08/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Early screening for psychological distress has been suggested to improve patient management for individuals experiencing low back pain. This study compared 2 approaches to psychological screening (ie, multidimensional and unidimensional) so that preliminary recommendations on which approach may be appropriate for use in clinical settings other than primary care could be provided. Specifically, this study investigated aspects of the STarT Back Screening Tool (SBT): 1) discriminant validity by evaluating its relationship with unidimensional psychological measures and 2) construct validity by evaluating how SBT risk categories compared to empirically derived subgroups using unidimensional psychological and disability measures. Patients (N = 146) receiving physical therapy for LBP were administered the SBT and a battery of unidimensional psychological measures at initial evaluation. Clinical measures consisted of pain intensity and self-reported disability. Several SBT risk-dependent relationships (ie, SBT low < medium < high risk) were identified for unidimensional psychological measure scores, with depressive symptom scores associated with the strongest influence on SBT risk categorization. Empirically derived subgroups indicated that there was no evidence of distinctive patterns among psychological or disability measures other than high or low profiles; therefore, 2 groups may provide a clearer representation of the level of pain-associated psychological distress, maladaptive coping, and disability in this setting compared with 3 groups as suggested when using the SBT in primary care settings. PERSPECTIVE This study suggests that the SBT can replace administering several unidimensional psychological measures as a first-line screening measure for psychological distress. However, clinicians need to be aware of the potential for misclassification with SBT results when compared to unidimensional measures. This study also suggests that a modified SBT risk stratification scheme based on empirically derived subgroups could potentially assist in identifying elevated levels of pain-associated psychological distress, maladaptive coping, and disability in practice settings outside of primary care. Patients identified with elevated levels of pain-associated distress and maladaptive coping may be indicated for additional assessment using construct-specific questionnaires.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, Florida; Brooks Rehabilitation-University of Florida College of Public Health and Health Professions Research Collaboration, Jacksonville, Florida.
| | - Michael E Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, Florida
| | - Steven Z George
- Department of Physical Therapy, University of Florida, Gainesville, Florida; Brooks Rehabilitation-University of Florida College of Public Health and Health Professions Research Collaboration, Jacksonville, Florida; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, Florida
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Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014; 2014:CD000963. [PMID: 25180773 PMCID: PMC10945502 DOI: 10.1002/14651858.cd000963.pub3] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the 'biopsychosocial model', has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds. OBJECTIVES To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term. SEARCH METHODS We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review. SELECTION CRITERIA All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds. DATA COLLECTION AND ANALYSIS Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity. MAIN RESULTS From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions.Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity. AUTHORS' CONCLUSIONS Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.
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Affiliation(s)
- Steven J Kamper
- The George Institute for Global HealthMusculoskeletal DivisionPO Box M201Missenden Road, CamperdownSydneyNSWAustralia2050
| | - Andreas T Apeldoorn
- VU University Medical CentreDepartment of Epidemiology and Biostatistics and the EMGO Institute for Health and Care ResearchAmsterdamNetherlands
| | - Alessandro Chiarotto
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesAmsterdamNetherlands
| | - Rob J.E.M. Smeets
- Maastricht University Medical CentreRehabilitation Medicine DepartmentDebyelaan 25PO Box 5800MaastrichtNetherlands6202 AZ
| | - Raymond WJG Ostelo
- VU UniversityDepartment of Health Sciences, EMGO Institute for Health and Care ResearchPO Box 7057AmsterdamNetherlands1007 MB
| | | | - Maurits W van Tulder
- VU UniversityDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
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Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions. Best Pract Res Clin Rheumatol 2014; 28:479-515. [DOI: 10.1016/j.berh.2014.07.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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