Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Hybrid Approach to Treatment Tailoring for Low Back Pain: A Proposed Model of Care

Various approaches have been used to guide the treatment of low back pain. These approaches have been considered in isolation and often tested against each other. An alternative view is that a model of care that involves a hybrid approach may benefit patients with low back pain. This commentary considers the potential benefits of a sequentially applied hybrid approach for treatment tailoring to optimize resource allocation to those most likely to require comprehensive care, and then decision making toward treatment paths with the greatest potential for success. In a first step, a prognosis-based approach, such as the Subgroups for Targeted Treatment Back Screening Tool (STarT Back), identifies individuals likely to require greater resource allocation. Although a clear path is indicated toward simple and psychologically informed care for the low- and high-risk groups, respectively, there is limited guidance for the large medium-risk group. For that group, the hybrid model provides a stepwise path of additional methods to guide treatment selection. This includes subgrouping based on pain mechanism to guide priority domains for the next phase, which includes tailoring of psychological and movement-based approaches. Motor control approaches to exercise would be indicated for individuals with medium risk and a nociceptive pain mechanism, with treatment guided by detailed assessment via one of several paradigms. Psychologically informed treatments are tailored to those with medium risk and a predominantly central pain mechanism, guided by detailed assessment of psychosocial features. A hybrid approach to a model of care could simplify treatment selection and take advantage of the benefits of each method in a time- and cost-efficient manner. J Orthop Sports Phys Ther 2019;49(6):453-463. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8774.

Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain

Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.

Changes in Structure and Function of the Back Muscles in Low Back Pain: Different Time Points, Observations, and Mechanisms

Spinal health depends on optimal back muscle performance, and this is determined by muscle structure and function. There has been substantial research evaluating the differences in structure and function of many back muscles, including the multifidus and erector spinae, but with considerable variation in results. Many studies have shown atrophy, fat infiltration, and connective tissue accumulation in back muscles, particularly deep fibers of the multifidus, but the results are not uniform. In terms of function, results are also somewhat inconsistent, often reporting lower multifidus activation and augmented recruitment of more superficial components of the multifidus and erector spinae, but, again, with variation between studies. A major recent observation has been the identification of time-dependent differences in features of back muscle adaptation, from acute to subacute/recurrent to chronic states of the condition. Further, these adaptations have been shown to be explained by different time-dependent mechanisms. This has substantial impact on the rationale for rehabilitation approaches. The aim of this commentary was to review and consolidate the breadth of research investigating adaptation in back muscle structure and function, to consider explanations for some of the variation between studies, and to propose how this model can be used to guide rehabilitation in a manner that is tailored to individual patients and to underlying mechanisms. J Orthop Sports Phys Ther 2019;49(6):464-476. doi:10.2519/jospt.2019.8827.

Motor Control Changes in Low Back Pain: Divergence in Presentations and Mechanisms

Compared to healthy individuals, patients with low back pain demonstrate differences in all aspects of trunk motor control that are most often studied as differences in muscle activity and kinematics. However, differences in these aspects of motor control are largely inconsistent. We propose that this may reflect the existence of 2 phenotypes or possibly the ends of a spectrum, with "tight control" over trunk movement at one end and "loose control" at the other. Both may have beneficial effects, with tight control protecting against large tissue strains from uncontrolled movement and loose control protecting against high muscle forces and resulting spinal compression. Both may also have long-term negative consequences. For example, whereas tight control may cause high compressive loading on the spine and sustained muscle activity, loose control may cause excessive tensile strains of tissues. Moreover, both phenotypes could be the result of either an adaptation process aimed at protecting the low back or direct interference of low back pain and related changes with trunk motor control. The existence of such phenotypes would suggest different motor control exercise interventions. Although some promising data supporting these phenotypes have been reported, it remains to be shown whether these phenotypes are valid, how treatment can be targeted to these phenotypes, and whether this targeting yields superior clinical outcomes. J Orthop Sports Phys Ther 2019;49(6):370-379. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7917.

Analysis of Motor Control in Patients With Low Back Pain: A Key to Personalized Care?

SYNOPSIS

Motor control exercise has been shown to be effective in the management of low back pain (LBP). However, the effect sizes for motor control exercise are modest, possibly because studies have used a one-size-fits-all approach, while the literature suggests that patients may differ in presence or type of motor control issues. In this commentary, we address the question of whether consideration of such variation in motor control issues might contribute to more personalized motor control exercise for patients with LBP. Such an approach is plausible, because motor control changes may play a role in persistence of pain through effects on tissue loading that may cause nociceptive afference, particularly in the case of peripheral sensitization. Subgrouping systems used in clinical practice, which comprise motor control aspects, allow reliable classification that is, in part, aligned with findings in studies on motor control in patients with LBP. Motor control issues may have heuristic value for treatment allocation, as the different presentations observed suggest different targets for motor control exercise, but this remains to be proven. Finally, clinical assessment of patients with LBP should take into account more aspects than motor control alone, including pain mechanisms, musculoskeletal health, and psychosocial factors, and may need to be embedded in a stratification approach based on prognosis to avoid undue diagnostic procedures. J Orthop Sports Phys Ther 2019;49(6):380-388. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7916.

Cognitive functional therapy (CFT)-based rehabilitation improves clinical outcomes in UK military personnel with persistent low back pain

Introduction

Low back pain (LBP) has been reported as the most common reason for presentation to the Medical Centre in the British Military, and the most common re-referral for the same condition. In 2015, the UK Defence Medical Rehabilitation Centre (DMRC) adopted a cognitive functional therapy (CFT) approach to spinal rehabilitation in line with National Institute for Health and Care Excellence and military best practice guidelines. The aim of this study is to evaluate the functional and psychosocial outcomes of all patients with chronic LBP treated with CFT-based multidisciplinary rehabilitation at DMRC, Headley Court.

Methods

A prospective observational service evaluation of British Military patients (n=238) with LBP who attended 3 weeks of inpatient multidisciplinary CFT-based programme from 2015 to the end of 2017 at DMRC was analysed. Functional outcomes include: multistage locomotion test (MSLT) and sit and reach test. Psychosocial outcomes include: Tampa Scale of Kinesiophobia, Oswestry Disability Index, Brief Pain Inventory (BPI), General Anxiety Disorder-7 and Patient Health Questionnaire-9.

Results

There were significant improvements in endurance (MSLT), range of motion, kinesiophobia, pain-related lifestyle interference (BPI-Lifestyle), anxiety and depression (p≤0.001). However, no improvements in pain intensity (BPI-Intensity) were demonstrated (p>0.05).

Conclusion

After 3 weeks of CFT-based multidisciplinary rehabilitation, function and psychosocial health improved with symptoms of pain being less obtrusive to activities of daily activity. There were however no patient-reported reductions in pain intensity. The improvements demonstrated are indicative of outcomes that facilitate greater integration back to work or into society.

Lumbar range of motion in chronic low back pain is predicted by task-specific, but not by general measures of pain-related fear

BACKGROUND

Most studies fail to show an association between higher levels of pain-related fear and protective movement behaviour in patients with chronic low back pain (CLBP). This may be explained by the fact that only general measures of pain-related fear have been used to examine the association with movement patterns. This study explored whether task-specific, instead of general measures of pain-related fear can predict movement behaviour.

METHODS

Fifty-five patients with CLBP and 54 healthy persons performed a lifting task while kinematic measurements were obtained to assess lumbar range of motion (ROM). Scores on the Photograph Daily Activities Series-Short Electronic Version (PHODA-SeV), Tampa Scale for Kinesiophobia and its Activity Avoidance and Somatic Focus subscales were used as general measures of pain-related fear. The score on a picture of the PHODA-SeV, showing a person lifting a heavy object with a bent back, was used as task-specific measure of pain-related fear.

RESULTS

Lumbar ROM was predicted by task-specific, but not by general measures of pain-related fear. Only the scores on one other picture of the PHODA-SeV, similar to the task-specific picture regarding threat value and movement characteristics, predicted the lumbar ROM. Compared to healthy persons, patients with CLBP used significantly less ROM, except the subgroup with a low score on the task-specific measure of pain-related fear, who used a similar ROM.

CONCLUSIONS

Our results suggest to use task-specific measures of pain-related fear when assessing the relationship with movement. It would be of interest to investigate whether reducing task-specific fear changes protective movement behaviour.

SIGNIFICANCE

This study shows that lumbar range of motion in CLBP is predicted by task-specific, but not by general measures of pain-related fear. This suggests that both in clinical practice and for research purposes, it might be recommended to use task-specific measures of pain-related fear when assessing the relationship with movement behaviour. This may help to disentangle the complex interactions between pain-related fear, movement and disability in patients with CLBP.

Managing low back pain in active adolescents

Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach - Cognitive Functional Therapy - which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent.

Development of pain in older adults: a latent class analysis of biopsychosocial risk factors

Pain significantly restricts the quality of life and well-being of older adults. With our increasingly ageing population, it is important to examine whether differing classes of biopsychosocial risk factors can predict the development of pain in older adults. Latent class analysis provides a model-based approach to identifying underlying subgroups in a population, based on some measured characteristics. In this study, latent class analysis was used to identify biopsychosocial risk classes in people aged 50 years and older, from The Irish Longitudinal Study on Ageing, who reported not often being troubled by pain at wave 1 and completed the 2-year follow-up at wave 2 (n = 4458). Four classes were identified based on 11 potential risk factors at wave 1. These classes were characterised as "Low Risk," "Physical Health Risk," "Mental Health Risk," and "High Risk." The Low-Risk class accounted for over half the sample (51.2%), whereas the High-Risk class represented 7.8% of the sample. At follow-up (wave 2), 797 (17.9%) participants reported being troubled by pain. Associations between the biopsychosocial risk classes and developing pain were examined using logistic regression, adjusting for sociodemographic variables. The High-Risk class was more likely to develop pain compared with the Low-Risk class (adjusted OR = 3.16, 95% CI = 2.40-4.16). These results add to existing data in other populations supporting the role of a range of biopsychosocial risk factors that increase the risk of developing pain. These findings have important implications for the identification, and potential moderation, of these risk factors.

Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review

Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP).  The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge's g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.

Integrating Mobile-health, health coaching, and physical activity to reduce the burden of chronic low back pain trial (IMPACT): a pilot randomised controlled trial

Background

Low back pain is one of the most prevalent musculoskeletal conditions and the highest contributor to disability in the world. It is characterized by frequent relapses leading to additional care-seeking. Engagement in leisure physical activity is associated with lower recurrences and better prognosis and potentially reduced care-seeking. Our aim was to investigate the feasibility and preliminary efficacy of a patient-centred physical activity intervention, supported by health coaching and mobile health, to reduce care-seeking, pain and disability in patients with chronic low back pain after treatment discharge.

Methods

We conducted a pilot randomised controlled trial with blinded outcome assessment. Sixty-eight participants were recruited from four public outpatient physiotherapy departments and the general community in Sydney. The intervention group received a physical activity information booklet, plus one face-to-face and 12 telephone-based health coaching sessions. The intervention was supported by an internet-based application and an activity tracker (Fitbit). Control group (standard care) received the physical activity information booklet and advice to stay active. Feasibility measures included recruitment rate, intervention compliance, data completeness, and participant satisfaction. Primary outcomes were care-seeking, pain levels and activity limitation. Outcomes were assessed at baseline, 6-month follow-up and weekly for 6 months.

Results

Ninety potential participants were invited over 15 months, with 68 agreeing to take part (75%). Overall, 903 weekly questionnaires were answered by participants from a total of 1107 sent (89%). Participants were largely satisfied with the intervention (mean = 8.7 out of 10 on satisfaction scale). Intervention group participants had a 38% reduced rate of care-seeking (Incidence Rate Ratio (IRR): 0.62, 95% CI: 0.32 to 1.18, p = 0.14, using multilevel mixed-effects Poisson regression analysis) compared to standard care, although none of the estimates was statistically significant. No between groups differences were found for pain levels or activity limitation.

Conclusion

The health coaching physical activity approach trialed here is feasible and well accepted by participants and may reduce care-seeking in patients with low back pain after treatment discharge, although further evaluation with an adequately powered trial is needed.

Trial registration

Australian and New Zealand Trial Registry ACTRN12615000189527. Registered prospectively on 26–02–2015.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2454-y) contains supplementary material, which is available to authorized users.

Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention

Objective

There are few effective treatments for acute whiplash-associated disorders (WAD). Early symptoms of postinjury stress predict poor recovery. This randomised controlled trial (StressModex) investigated whether physiotherapist-led stress inoculation training integrated with exercise is more effective than exercise alone for people with acute WAD.

Methods

108 participants (<4 weeks) at risk of poor recovery (moderate pain-related disability and hyperarousal symptoms) were randomly assigned by concealed allocation to either physiotherapist-led stress inoculation training and guideline-based exercise (n=53) or guideline-based exercise alone (n=55). Both interventions comprised 10 sessions over 6 weeks. Participants were assessed at 6 weeks and at 6 and 12 months postrandomisation. Analysis was by intention to treat using linear mixed models.

Results

The combined stress inoculation training and exercise intervention was more effective than exercise alone for the primary outcome of pain-related disability at all follow-up points. At 6 weeks, the treatment effect on the 0–100 Neck Disability Index was (mean difference) −10 (95% CI −15.5 to −4.48), at 6 months was −7.8 (95% CI −13.8 to −1.8) and at 12 months was −10.1 (95% CI −16.3 to −4.0). A significant benefit of the stress inoculation and exercise intervention over exercise alone was also found for some secondary outcomes.

Conclusion

A physiotherapist-led intervention of stress inoculation training and exercise resulted in clinically relevant improvements in disability compared with exercise alone—the most commonly recommended treatment for acute WAD. This contributes to the case for physiotherapists to deliver an early psychological intervention to patients with acute WAD who are otherwise at high risk of a poor outcome.

Trial registration number

ACTRN12614001036606.

Does movement matter in people with back pain? Investigating 'atypical' lumbo-pelvic kinematics in people with and without back pain using wireless movement sensors

Background

Interventions for low back pain (LBP) commonly target ‘dysfunctional’ or atypical lumbo-pelvic kinematics in the belief that correcting aberrant movement improves patients’ pain and activity outcomes. If atypical kinematic parameters and postures have a relationship to LBP, they could be expected to more prevalent in people with LBP compared to people without LBP (NoLBP). This exploratory study measured, defined and compared atypical kinematic parameters in people with and without LBP.

Methods

Wireless inertial motion and EMG sensors were used to measure lumbo-pelvic kinematics during standing trunk flexion (range of motion (ROM), timing, sequence coordination, and extensor muscle activation) and in sitting (relative sitting position, pelvic tilt range) in a sample of 126 of adults without LBP and 140 chronic LBP subjects. Atypical movement was defined using the 10th/90th centiles of the NoLBP group. Mean differences and prevalence rates for atypical movement were calculated. Dichotomised pain scores for ‘high-pain-on-bending’ and ‘high-pain-on-sitting’ were tested for their association with atypical kinematic variables.

Results

For standing flexion, significant mean differences, after adjusting for age and gender factors, were seen for the LBP group with (i) reduced ROM (trunk flexion (NoLBP 111^o, LBP 93^o, p < .0001), lumbar flexion (NoLBP 52^o, LBP 46^o, p < .0001), pelvic flexion (NoLBP 59^o, LBP 48^o, p < .0001), (ii) greater extensor muscle activation for the LBP group (NoLBP 0.012, LBP 0.25 p < .0001), (iii) a greater delay in pelvic motion at the onset of flexion (NoLBP − 0.21 s; LBP − 0.36 s, p = 0.023), (iv) and longer movement duration for the LBP group (NoLBP 2.28 s; LBP 3.18 s, p < .0001). Atypical movement was significantly more prevalent in the LBP group for small trunk (× 5.4), lumbar (× 3.0) and pelvic ROM (× 3.9), low FRR (× 4.9), delayed pelvic motion at 20^o flexion (× 2.9), and longer movement duration (× 4.7). No differences between groups were seen for any sitting parameters. High pain intensity was significantly associated with small lumbar ROM and pelvic ROM.

Conclusion

Significant movement differences during flexion were seen in people with LBP, with a higher prevalence of small ROM, slower movement, delayed pelvic movement and greater lumbar extensor muscle activation but without differences for any sitting parameter.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2387-x) contains supplementary material, which is available to authorized users.

STarT Back Tool risk stratification is associated with changes in movement profile and sensory discrimination in low back pain: A study of 290 patients

BACKGROUND

Investigation of movement and sensory profiles across STarT Back risk subgroups.

METHODS

A chronic low back pain cohort (n = 290) were classified as low, medium or high risk using the STarT Back Tool, and completed a repeated spinal bending task and quantitative sensory testing. Pain summation, time taken and the number of protective behaviours with repeated bending were measured. Sensory tests included two-point discrimination, temporal summation, pressure/thermal pain thresholds and conditioned pain modulation. Subgroups were profiled against movement and sensory variables.

RESULTS

The high-risk subgroup demonstrated greater pain summation following repeated forward bending (p < 0.001). The medium-risk subgroup demonstrated greater pain summation following repeated backward bending (p = 0.032). Medium- and high-risk subgroups demonstrated greater forward/backward bend time compared to the low-risk subgroup (p = 0.001, p = 0.005, respectively). Medium- and high-risk subgroups demonstrated a higher number of protective behaviours per forward bend compared to the low-risk subgroup (p = 0.008). For sensory variables, only two-point discrimination differed between subgroups, with medium- and high-risk subgroups demonstrating higher thresholds (p = 0.016).

CONCLUSIONS

This study showed altered movement characteristics and sensory discrimination across SBT risk subgroups in people with CLBP. Membership of the high SBT risk subgroup was associated with greater pain and disability levels, greater pain summation following repeated bending, slower bending times, a greater number of protective behaviours during forward bending, and a higher TPD threshold. Treatment outcomes for higher risk SBT subgroups may be enhanced by interventions specifically targeting movement and sensory alterations.

SIGNIFICANCE

In 290 people with chronic low back pain movement profile and two-point discrimination threshold differed across risk subgroups defined by the STarT Back Tool. Conversely, pain sensitivity did not differ across these subgroups. These findings may add further guidance for targeted care in these subgroups.

Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review

Background and Objective

Recent systematic reviews show promising effects for multidisciplinary biopsychosocial (BPS) interventions in patients with chronic low back pain (CLBP). Nowadays, BPS interventions have also been developed for primary care physiotherapy settings. Our aim was to systematically review the evidence on the effectiveness of primary care BPS interventions in improving functional disability, pain, and work status for patients with CLBP. Secondly, we aimed to provide an elaborated overview of BPS intervention designs, physiotherapist training programs, and process‐related factors (practical implementation).

Methods

We searched in scientific databases and reference lists. Randomized controlled trials (RCTs) evaluating primary care physiotherapist‐led BPS interventions in adults (≥18 years) with nonspecific CLBP (≥12 weeks) were included.

Results

Our search resulted in 943 references; 7 RCTs were included (1,426 participants). Results show moderate‐quality evidence (3 trials; 991 participants) that a BPS intervention is more effective than education/advice for reducing disability and pain in the short, medium, and long term. Low‐quality evidence (4 trials; 435 participants) was found for no difference with physical activity treatments.

Conclusions

BPS interventions seem more effective than education/advice and were found to be as effective as physical activity interventions in patients with CLBP. BPS interventions with a clear focus on psychosocial factors (understanding pain, unhelpful thoughts, coping styles, and goal setting) seem most promising. Sufficient delivery of BPS elements is expected when physiotherapists participate in training programs with extensive support prior and during delivery (manual, supervision, and informative resources).

Buy-In for Back Pain: Does Individualization Matter?

Background: The aim of this study was to investigate the effect of individualization of an exercise program on the buy-in received from chronic low back pain (CLBP) patients.

Methods: Participants were randomized to 8 weeks of an individualized (IEP) or general exercise program (GEP). All participants were required to attend one 1:1 session per week with an exercise physiologist and 4 home-based sessions. Clinical outcomes were assessed with the Oswestry Disability Index (ODI) and visual analog pain scale (VAS) measured before and after the 8-week intervention along with barrier self-efficacy and adherence. Additionally, multidimensional outcome expectations, exercise self-efficacy, and intention to exercise were measured before the intervention, after the first session, and after 8 weeks. Measures were taken after the first session to observe if clinical assessment and informing the patient that the program was individualized manipulated beliefs differently compared to providing a GEP. Beliefs about the program after the first session were elevated in both groups.

Results: Adherence to the supervised and home-based sessions was high and similar between groups. Clinical outcome measures were similar with both groups showing significant reduction from baseline in the ODI (P ≤ 0.01).

Conclusion: Thus, it appears an individualized program is no more beneficial than a GEP for CLBP. Clinically, it appears a GEP is an intelligent choice for practitioners as it negates the need for clinical assessments, which appear to add no benefit to outcomes or adherence.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study

BACKGROUND

It has long been acknowledged that nonspecific chronic low back pain (NSCLBP) is associated with a complex combination of biopsychosocial (BPS) factors, and recent guidelines advocate that the management of back pain should reflect this multidimensional complexity. Cognitive functional therapy (CFT) is a behaviourally oriented intervention that targets patients' individual BPS profiles. Although the efficacy of CFT has been demonstrated in primary care, little evidence exists about the training requirements of this approach.

METHODS

Qualitative semistructured interviews were conducted with 10 physiotherapists working in primary care, who had undergone a formal training programme in CFT. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes.

RESULTS

Five main themes emerged: (i) the learning challenge; (ii) self-reported changes in confidence; (iii) self-reported changes in communication practice; (iv) self-reported changes in attitudes and understanding; (v) the physiotherapists felt that CFT was more effective than their usual approach for NSCLBP but identified barriers to successful implementation, which included a lack of time and difficulties in engaging patients with strong biomedical beliefs.

CONCLUSIONS

The study suggested that training in CFT has the capacity to produce self-reported changes in physiotherapists' attitudes, confidence and practice. The provision of such training has implications in terms of time and costs; however, this this may be warranted, given the physiotherapists' strong allegiance to the approach compared with their usual practice.

The Impact of Depression on Patient Outcomes in Hip Arthroscopic Surgery

Background:

Mental health impairments have been shown to negatively affect preoperative self-reported function in patients with various musculoskeletal disorders, including those with femoroacetabular impingement.

Hypothesis:

Those with symptoms of depression will have lower self-reported function, more pain, and less satisfaction on initial assessment and at 2-year follow-up than those without symptoms of depression.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who were enrolled in a multicenter hip arthroscopic surgery registry and had 2-year outcome data available were included in the study. Patients completed the 12-item International Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and 12-item Short-Form Health Survey (SF-12) when consenting for surgery. At 2-year follow-up, patients were emailed the iHOT, the VAS, and a rating scale of surgical satisfaction. Initial SF-12 mental component summary (MCS) scores <46.5 and ≤36 were used to qualify symptoms of depression and severe depression, respectively, as previously described and validated. Repeated-measures analysis of variance was performed to compare preoperative and 2-year postoperative iHOT-12, VAS, and satisfaction scores between those with and without symptoms of depression.

Results:

A total of 781 patients achieved the approximate 2-year milestone (mean follow-up, 735 ± 68 days), with 651 (83%) having 2-year outcome data available. There were 434 (67%) female and 217 (33%) male patients, with a mean age of 35.8 ± 13.0 years and a mean body mass index of 25.4 ± 8.8 kg/m². The most common procedures were femoroplasty (83%), followed by synovectomy (80%), labral repair (76%), acetabuloplasty (58%), acetabular chondroplasty (56%), femoral chondroplasty (23%), and labral reconstruction (19%). The mean initial SF-12 MCS score was 51.5 ± 10.3, with cutoff scores indicating symptoms of depression and severe depression in 181 (28%) and 71 (11%) patients, respectively. Patients with symptoms of depression scored significantly (P < .05) lower on the initial iHOT-12 and VAS and 2-year follow-up iHOT-12, VAS, and rating scale of surgical satisfaction.

Conclusion:

A large number of patients who underwent hip arthroscopic surgery presented with symptoms of depression, which negatively affected self-reported function, pain levels, and satisfaction on initial assessment and at 2-year follow-up. Surgeons who perform hip arthroscopic surgery may need to identify the symptoms of depression and be aware of the impact that depression can have on surgical outcomes.

Patients' perceived needs for medical services for non-specific low back pain: A systematic scoping review

BACKGROUND

An improved understanding of patients' perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients' perceived needs for medical services for LBP.

METHODS

A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs for medical services for LBP were categorised.

RESULTS

50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients' preferences for medications. (3) Of the few studies which examined the patients' perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms.

CONCLUSIONS

Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.

The Ratio of Lumbar to Hip Motion during the Trunk Flexion in Patients with Mechanical Chronic Low Back Pain According to O'Sullivan Classification System: A Cross-sectional Study

BACKGROUND

Static and dynamic postures of lumbopelvic in low back pain (LBP) are considered as two important aspects of clinical assessment and management of LBP. Thus, the focus of the current study was to compare the posture and compensatory strategy of hip and lumbar region during trunk flexion between LBP subgroupsand health subjects. LBP cases are subdivided into active extension pattern (AEP) and flexion pattern (FP) based on O'Sullivan's classification system (OCS).

METHODS

This work was a cross-sectional study involving 72 men, 21 low back pain patients with FP and 31 low back pain patients with AEP and 20 healthy groups. Lumbar and hip angles during trunk flexion were measured by a 3D motion analysis system in neutral standing posture and end-range of trunk flexion. The participants were asked to full bend without any flexion of the knees. The bending speed was preferential. Hip and lumbar ranges of motion were divided into four quartiles (Q). The quartiles were compared between groups. Data analysis was performed using one-way analysis of variance (ANOVA) and independent t-test.

RESULTS

There was no statistically significant difference in lumbar lordosis in standing and full trunk flexion positions between the healthy groups and heterogeneous LBP groups. In addition, there was not any statistically significant difference between the healthy group and the homogenous LBP group (FP and AEP). Moreover, no statistically significant difference was observed in hip angles during standing between the healthy group and the heterogeneous LBP group, and between the healthy group and the homogenous LBP group (FP and AEP). In full trunk flexion position, there was statistically significant difference in hip angles between the healthy group and the heterogeneous LBP group (P=0.026). In this position, the difference in hip angles between the healthy group and FP group was statistically significant (P<0.05). In the second Q, there was no significant difference between the healthy group and the heterogeneous LBP group (P=0.062), however, there was a significant difference between FP group and the healthy group in the fourth Q of the total hip range of motion. There was no statistically significant difference between the healthy group and the heterogeneous LBP group (P=0.054) but there was a difference between FP group and the healthy group. Lumbar/hip motion ratio (L/H ratio) was different between and within the subgroups in the second Q.

CONCLUSION

This study supported the subgrouping of LBP and showed that the difference between subgroups could be determined effectively through subdividing the total range of lumbar and hip motions into smaller portions. It is possible that the neuromuscular system selects different strategies to compensate and prevent further injury of the chain components (muscle, joint, nerve and etc.).

LEVEL OF EVIDENCE

IV.

Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review

OBJECTIVES

Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP.

METHODS

A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated.

RESULTS

Forty-four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed-methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short-term duration of these therapies.

CONCLUSIONS

Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient-centred guidelines and service models for LBP. Understanding patients' concerns regarding active-based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health-care system.

Sensor-based postural feedback is more effective than conventional feedback to improve lumbopelvic movement control in patients with chronic low back pain: a randomised controlled trial

Background

Improving movement control can be an important treatment goal for patients with chronic low back pain (CLBP). Although external feedback is essential when learning new movement skills, many aspects of feedback provision in patients with CLBP remain currently unexplored. New rehabilitation technologies, such as movement sensors, are able to provide reliable and accurate feedback. As such, they might be more effective than conventional feedback for improving movement control. The aims of this study were (1) to assess whether sensor-based feedback is more effective to improve lumbopelvic movement control compared to feedback from a mirror or no feedback in patients with chronic low back pain (CLBP), and (2) to evaluate whether patients with CLBP are equally capable of improving lumbopelvic movement control compared to healthy persons.

Methods

Fifty-four healthy participants and 54 patients with chronic non-specific LBP were recruited. Both participant groups were randomised into three subgroups. During a single exercise session, subgroups practised a lumbopelvic movement control task while receiving a different type of feedback, i.e. feedback from movement sensors, from a mirror or no feedback (=control group). Kinematic measurements of the lumbar spine and hip were obtained at baseline, during and immediately after the intervention to evaluate the improvements in movement control on the practised task (assessment of performance) and on a transfer task (assessment of motor learning).

Results

Sensor-based feedback was more effective than feedback from a mirror (p < 0.0001) and no feedback (p < 0.0001) to improve lumbopelvic movement control performance (Sensor vs. Mirror estimated difference 9.9° (95% CI 6.1°-13.7°), Sensor vs. Control estimated difference 10.6° (95% CI 6.8°-14.3°)) and motor learning (Sensor vs. Mirror estimated difference 7.2° (95% CI 3.8°-10.6°), Sensor vs. Control estimated difference 6.9° (95% CI 3.5°-10.2°)). Patients with CLBP were equally capable of improving lumbopelvic movement control compared to healthy persons.

Conclusions

Sensor-based feedback is an effective means to improve lumbopelvic movement control in patients with CLBP. Future research should focus on the long-term retention effects of sensor-based feedback.

Trial registration

clinicaltrials.gov NCT02773160, (retrospectively registered on May 16th, 2016).

Electronic supplementary material

The online version of this article (10.1186/s12984-018-0423-6) contains supplementary material, which is available to authorized users.

Subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain

BACKGROUND

Movement dysfunctions have been associated with persistent low back pain (LBP) but optimal treatment remains unclear. One possibility is that subgroups of persistent LBP patients have differing movement characteristics and therefore different responses to interventions. This study examined if there were patterns of flexion-related lumbo-pelvic kinematic and EMG parameters that might define subgroups of movement.

METHODS

This was a cross-sectional, observational study of 126 people without any history of significant LBP and 140 people with persistent LBP (n = 266). Wireless motion and surface EMG sensors collected lumbo-pelvic data on flexion parameters (range of motion (ROM) of trunk, lumbar, and pelvis), speed, sequence coordination and timing, and EMG extensor muscle activity in forward bending (flexion relaxation)), and sitting parameters (relative position, pelvic tilt range and tilt ratio). Latent class analysis was used to identify patterns in these parameters.

RESULTS

Four subgroups with high probabilities of membership were found (mean 94.9%, SD10.1%). Subgroup 1 (n = 133 people, 26% LBP) had the greatest range of trunk flexion, fastest movement, full flexion relaxation, and synchronous lumbar versus pelvic movement. Subgroup 2 (n = 73, 71% LBP) had the greatest lumbar ROM, less flexion relaxation, and a 0.9 s lag of pelvic movement. Subgroup 3 (n = 41, 83% LBP) had the smallest lumbar ROM, a 0.6 s delay of lumbar movement (compared to pelvic movement), and less flexion relaxation than subgroup 2. Subgroup 4 (n = 19 people, 100% LBP) had the least flexion relaxation, slowest movement, greatest delay of pelvic movement and the smallest pelvic ROM. These patterns could be described as standard (subgroup 1), lumbar dominant (subgroup 2), pelvic dominant (subgroup 3) and guarded (subgroup 4). Significant post-hoc differences were seen between subgroups for most lumbo-pelvic kinematic and EMG parameters. There was greater direction-specific pain and activity limitation scores for subgroup 4 compared to other groups, and a greater percentage of people with leg pain in subgroups 2 and 4.

CONCLUSION

Four subgroups of lumbo-pelvic flexion kinematics were revealed with an unequal distribution among people with and without a history of persistent LBP. Such subgroups may have implications for which patients are likely to respond to movement-based interventions.

Effectiveness of movement control exercise on patients with non-specific low back pain and movement control impairment: A systematic review and meta-analysis

BACKGROUND

Patients with low back pain (LBP) and movement control impairment (MVCI) show altered spinal movement patterns. Treatment that aims to change movement behaviour could benefit these patients.

OBJECTIVE

To assess the effectiveness of movement control exercise (MVCE) in terms of clinically relevant measures (disability and pain) on patients with NSLBP.

METHODS

A systematic review and meta-analysis were conducted. CINAHL, MEDLINE, PUBMED and PEDro databases were searched for RCT's evaluating MVCE treatment in patients with NSLBP from review inception to April 2017. Authors were contacted to obtain missing data and outcomes. PEDro was used to assess methodological quality of the studies and the GRADE approach was used to assess the overall quality of evidence Data were combined using a random effects meta-analysis and reported as standardized mean differences (SMD).

RESULTS

Eleven eligible RCT's including a total of 781 patients were found. Results show 'very low to moderate quality' evidence of a positive effect of MVCE on disability, both at the end of treatment and after 12 months (SMD -0.38 95%CI -0.68, -0.09 respectively 0.37 95%CI -0.61,-0.04). Pain intensity was significantly reduced after MVCE at the end of treatment (SMD -0.39 95%CI -0.69, -0.04), but not after 12 months (SMD -0.27, 95%CI -0.62, 0.09).

CONCLUSIONS

MVCE intervention for people with NSLBP and MVCI appears to be more effective in improving disability compared to other interventions, both over the short and long term. Pain was reduced only in the short term. An important factor is the initial identification of patients with MVCI. Registration of the study: The study protocol registration number is CRD42016036662 on PROSPERO.

Efficacy of two brief cognitive-behavioral rehabilitation programs for chronic neck pain: results of a randomized controlled pilot study

BACKGROUND

Current models of pain behavior suggest that kinesiophobia prevents the reacquisition of normal function, promotes the development of maladaptive coping strategies, and contributes to the disability associated with chronic neck pain (NP).

AIM

Comparing two brief cognitive-behavioral programs aimed at managing kinesiophobia to understand which one induces better short-term improvements in disability, fear of movement, catastrophizing, adaptive coping strategies, quality of life (QoL), and pain intensity of chronic NP.

DESIGN

Pilot, randomized, controlled trial, 3-months follow-up.

SETTING

Outpatients.

POPULATION

Subjects with chronic NP.

METHODS

The population was randomized into two groups: group A (N.=15) underwent four sessions of cognitive-behavioral therapy (CBT) based on the NeckPix© (1-week duration); group B (N.=15) received four sessions of CBT based on the Tampa Scale of Kinesiophobia (TSK) (1-week duration). Afterwards, both groups attended 10 sessions of multimodal exercises (5-week duration). Primary measure: Neck Disability Index (NDI). Secondary measures: NeckPix©, TSK, Pain Catastrophizing Scale, Chronic Pain Coping Inventory, EuroQol-Five Dimensions, and pain intensity Numerical Rating Scale.

STATISTICS

Linear mixed model analyses for repeated measures for each outcome measure to evaluate changes over time and between group.

RESULTS

A significant effect of time was found for all outcomes, while no outcomes showed group and/or interaction effects. No changes were found in terms of NDI at the end of CBT, while a significant improvement of about 13 points was found for both groups at the end of the motor training (P=0.001). Similarly, in terms of quality of life there was no change after the CBT program, and a significant change at the end of the motor training, with a partial loss at follow-up. From CBT sessions to follow-up both groups showed a progressive reduction in kinesiophobia, with each group achieving a bigger change in the specific scale used for the CBT program.

CONCLUSIONS

Two brief cognitive-behavioral rehabilitation programs based on different methodologies of managing fear-avoidance beliefs induced similar short-term improvements in subjects with chronic NP. Clinically significant changes in terms of disability were found in both groups only at the end of a 5-week motor training, regardless of the cognitive-behavioral rehabilitation program previously administrated.

CLINICAL REHABILITATION IMPACT

Treatment of chronic NP requires cognitive modifications closely linked to physical performances in order to achieve mental adjustments and guarantee cognitive-behavioral as well as motor lasting changes.

The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice

The diversity of models of care in contemporary musculoskeletal physical therapy can be confusing for patients and practicing clinicians. There is, however, a common theme to many of these seemingly disparate models of care: symptom modification. Symptom modification aims at reducing symptoms and improving function with a variety of clinical approaches. This Viewpoint explores the role of symptom modification in rehabilitation and specifically addresses (1) symptom modification within the kinesiopathological model of pain, (2) symptom modification in clinical practice, and (3) potential commonality in seemingly divergent models of clinical practice. J Orthop Sports Phys Ther 2018;48(6):430-435. doi:10.2519/jospt.2018.0608.

Chronic low back pain: a mini-review on pharmacological management and pathophysiological insights from clinical and pre-clinical data

Globally, low back pain (LBP) is one of the most common health problems affecting humans. The lifetime prevalence of non-specific LBP is approximately 84%, with the chronic prevalence at about 23%. Chronic LBP in humans is defined as LBP that persists for more than 12 weeks without a significant pain improvement. Although there are numerous evidence-based guidelines on the management of acute LBP, this is not the case for chronic LBP, which is regarded as particularly difficult to treat. Research aimed at discovering new drug treatments for alleviation of chronic mechanical LBP is lacking due to the paucity of knowledge on the pathobiology of this condition, despite its high morbidity in the affected adult population. For a debilitating condition such as chronic LBP, it is necessary to assess the sustained effects of pharmacotherapy of various agents spanning months to years. Although many rodent models of mechanical LBP have been developed to mimic the human condition, some of the major shortcomings of many of these models are (1) the presence of a concurrent neuropathic component that develops secondary to posterior intervertebral disc puncture, (2) severe model phenotype, and/or (3) use of behavioural endpoints that have yet to be validated for pain. Hence, there is a great, unmet need for research aimed at discovering new biological targets in rodent models of chronic mechanical LBP for use in drug discovery programs as a means to potentially produce new highly effective and well-tolerated analgesic agents to improve relief of chronic LBP. On a cautionary note, it must be borne in mind that because humans and rats display orthograde and pronograde postures, respectively, the different mechanical forces on their spines add to the difficulty in translation of promising rodent data to humans.

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis

BACKGROUND CONTEXT

Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.

PURPOSE

The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.

STUDY DESIGN/SETTING

This is a systematic literature review and meta-analysis.

OUTCOME MEASURES

The present study measures self-reported pain, function, health-related quality of life, and adverse events.

METHODS

We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.

RESULTS

Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=-0.28, 95% confidence interval (CI) -0.47 to -0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=-0.33, 95% CI -0.63 to -0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=-0.43, 95% CI -0.86 to 0.00; p=.05, I2=79%; SMD=-0.86, 95% CI -1.27 to -0.45; p<.0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=-0.20, 95% CI -0.35 to -0.04; p=.01; I2=0%) but not disability (SMD=-0.10, 95% CI -0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described.

CONCLUSION

There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual's disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

Physical therapy clinical specialization and management of red and yellow flags in patients with low back pain in the United States

Objectives

Physical therapists (PTs) may practice in direct access or act as primary care practitioners, which necessitate patients' screening and management for red, orange and yellow flags. The objective of the project was to assess the American PT's ability to manage red, orange and yellow flags in patients with low back pain (LBP), and to compare this ability among PTs with different qualifications.

Methods

The project was an electronic cross-sectional survey. The investigators contacted 2,861 PTs. Participants made clinical decisions for three vignettes: LBP with red flag for ectopic pregnancy, with orange flag for depression and with yellow flag for fear avoidance behaviour (FAB). The investigators used logistic regression to compare management of warning flags among PTs with distinct qualifications: orthopaedic clinical specialists (PTOs), fellows of the AAOMPT (PTFs), PTOs and PTFs (PTFOs), and PTs without clinical specialization (PTMSs).

Results

A total of 410 PTs completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs and 84 PTMSs). Two hundred and seventeen PTs (53%) managed the patient with LBP and symptoms of ectopic pregnancy correctly, 115 PTs (28.5%) of them managed the patient with LBP and symptoms of depression correctly, and 177 (43.2%) managed the patient with LBP and FAB correctly.

Discussion

In general, PTs with specialization performed significantly better than PTMSs in all three clinical vignettes. PTs ability to manage patients with warning flags was relatively low. Based on our results, further education on patients with LBP and warning flags is needed. The survey had the potential for non-response and self-selection bias.

Level of Evidence

3b.

Serious Gaming to Support Exercise Therapy for Patients with Chronic Nonspecific Low Back Pain: A Feasibility Study

OBJECTIVE

To investigate the feasibility of a functional exercise program supported by serious gaming for patients with chronic nonspecific low back pain (LBP).

METHODS

Ten patients with chronic nonspecific LBP and an underlying motor control impairment were recruited. Subjects performed a partially supervised exercise program (36 sessions, 18 weeks) that included 30 minutes of general conditioning and 90 minutes of individually tailored functional motor control exercises (MCEs). Serious games (SGs) were used to (1) improve thoracolumbar dissociation and (2) to provide postural feedback during functional MCEs. The SGs were also available at home.

RESULTS

Treatment satisfaction and the scores on the credibility/expectancy questionnaire were good and did not change throughout the intervention. Patients remained motivated throughout the rehabilitation program and no serious adverse events were reported. Overall, participants indicated that the SGs helped them to perform the home exercises more correctly, and as a consequence, they felt more confident doing them. However, the time needed to set up the games was a barrier for home use and participants would have found it useful to receive postural feedback during daily life activities.

CONCLUSIONS

It is feasible to support a functional exercise program with SGs for patients with chronic nonspecific LBP, both in a supervised and a home environment. Time-efficiency and the integration of SGs in daily life activities are challenges that need to be addressed in the future.

Motor skill training in musculoskeletal pain: a case report in chronic low back pain

Purpose: Low back pain is a chronic condition that limits function. The chief reason individuals with low back pain seek care is difficulty performing functional activities. A novel approach to improving performance of painful and limited functional activities is motor skill training, defined as challenging practice of activities to learn or relearn a skill. The purpose of this report is to describe the design and application of a motor skill training intervention in a 26-year-old man with a 10-year history of low back pain. Methods: A motor skill training intervention was implemented to modify the altered alignment and movement patterns he used during the performance of his painful and limited activities. Results: The patient was seen for six visits in 12 weeks. The patient reported decreased pain and medication use, as well as improved function immediately, 3-, and 9-months post-intervention. Conclusion: Individuals with low back pain report limitation in ability to perform everyday functions and demonstrate altered patterns of movement and alignment during these activities. This case report describes an innovative motor skill training intervention that directly addresses the performance of functional activities and the application of motor learning principles. Implications for rehabilitation Low back pain is a chronic condition that limits function. The chief reason individuals with chronic low back pain seek care is difficulty performing everyday functional activities. Motor skill training is a novel approach that directly addresses the performance of painful and limited functional activities through challenging practice to improve performance and decrease pain.

Recovering from provoked vestibulodynia: Experiences from encounters with somatocognitive therapy

Although provoked vestibulodynia (PVD) represents a significant challenge for many young women in the Western world, little is known about how these women experience therapeutic efforts. The aim of this paper is to enhance our knowledge of the way that the therapeutic process is experienced by women with PVD undergoing somatocognitive therapy (SCT). The study enhances insight into this recently developed therapy through a detailed description of the physiotherapy approach. The empirical data are based on interviews with six women who participated in SCT. The empirical data analysis is guided by thematic analysis. Our findings demonstrate how the women experience SCT as a bodily process of wholeness. The process of wholeness relates to new experiences in the women's own bodies, awareness of muscular and mental tension and relaxation, breathing patterns, and perceptions focusing on pain. The findings are presented as three interrelated themes: 1) sensitizing the body as an interconnected unit; 2) incorporating the painful pubic region into the body; and 3) developing a new understanding of oneself. The women who participated in this study found that SCT contributed significantly to the process of their recovery from PVD.

Exploring the lived experience and chronic low back pain beliefs of English-speaking Punjabi and white British people: a qualitative study within the NHS

INTRODUCTION

Disabling chronic low back pain (CLBP) is associated with negative beliefs and behaviours, which are influenced by culture, religion and interactions with healthcare practitioners (HCPs). In the UK, HCPs encounter people from different cultures and ethnic backgrounds, with South Asian Indians (including Punjabis) forming the largest ethnic minority group. Better understanding of the beliefs and experiences of ethnic minorities with CLBP might inform effective management.

OBJECTIVES

To explore the CLBP beliefs and experiences of English-speaking Punjabi and white British people living with CLBP, explore how beliefs may influence the lived experience of CLBP and conduct cross-cultural comparisons between the two groups.

DESIGN

Qualitative study using semistructured interviews set within an interpretive description framework and thematic analysis.

SETTING

A National Health Service hospital physiotherapy department, Leicester, UK.

PARTICIPANTS

10 CLBP participants (5 English-speaking Punjabi and 5 white British) purposively recruited from physiotherapy waiting lists.

RESULTS

Participants from both groups held negative biomedical CLBP beliefs such as the 'spine is weak', experienced unfulfilling interactions with HCPs commonly due to a perceived lack of support and negative psychosocial dimensions of CLBP with most participants catastrophising about their CLBP. Specific findings to Punjabi participants included (1) disruption to cultural-religious well-being, as well as (2) a perceived lack of understanding and empathy regarding their CLBP from the Punjabi community. In contrast to their white British counterparts, Punjabi participants reported initially using passive coping strategies; however, all participants reported a transition towards active coping strategies.

CONCLUSION

CLBP beliefs and experiences, irrespective of ethnicity, were primarily biomedically orientated. However, cross-cultural differences included cultural-religious well-being, the community response to CLBP experienced by Punjabi participants and coping styles. These findings might help inform management of people with CLBP.

Rehabilitation of a Young Athlete With Extension-Based Low Back Pain Addressing Motor-Control Impairments and Central Sensitization

OBJECTIVE

  To describe the conservative management of a young athlete with extension-based (EB) low back pain (LBP).

BACKGROUND

  We present the case of a 15-year-old female high school gymnast with a 4-year history of EB LBP. Magnetic resonance imaging revealed a healed spondylolysis and significant atrophy with fatty infiltrate of the lumbar multifidi muscles (LMM). She had several courses of outpatient orthopaedic rehabilitation that focused on core muscle strengthening (improving activation and strength of the LMM and transversus abdominus muscle in a neutral pelvic position) without long-lasting improvement. She was unable to tolerate higher levels of training or compete.

DIFFERENTIAL DIAGNOSIS

  The LMM are rich in muscle spindles and provide continuous feedback to the central nervous system about body position. Atrophy and fatty infiltrate of the LMM can compromise neuromuscular function and contribute to dysfunctional movement patterns that place a greater demand on lumbar spine structures. Ongoing motor-control impairments perpetuate nociceptive input, leading to central sensitization.

TREATMENT

  The athlete had difficulty controlling trunk extension during sport-specific activities; she moved early and to a greater extent in the lumbar spine. The aim of the treatment was to teach the athlete how to control her tendency to overload her lumbar spine when bending backward, thus reducing nociceptive input from lumbar spine structures and desensitizing the nervous system.

UNIQUENESS

  Treating EB LBP by addressing motor-control impairments and cognitive-affective factors as opposed to core strengthening.

CONCLUSIONS

  Activity modification, bracing, and traditional core-strengthening exercises may not be the most appropriate treatment for athletes experiencing EB LBP. Addressing cognitive-affective factors in addition to correcting maladaptive motor behavior and moving in a pain-free range reduces nociceptive input, desensitizes the nervous system, and allows athletes to gain control over their pain.

Movement System Impairment-Based Classification Treatment Versus General Exercises for Chronic Low Back Pain: Randomized Controlled Trial

Background

Treatment for chronic low back pain (LBP) includes different forms of exercises, that to date have resulted in only small to moderate treatment effects. To enhance the treatment effects, different classification systems have been developed to classify people with LBP into more homogeneous subgroups leading to specific treatments for each subgroup.

Objective

The purpose of this study was to compare the efficacy of a treatment based on the Movement System Impairment (MSI) model with a treatment consisting of symptom-guided stretching and strengthening exercises in people with chronic LBP.

Design

The study was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor.

Setting

The study setting was a university physical therapy clinic in Brazil.

Patients

A total of 148 participants with chronic LBP participated in the study.

Interventions

Participants were randomly allocated to an 8-week treatment of either treatment based on the MSI-based classification system or symptom-guided stretching and strengthening exercises.

Measurements

Measures of pain intensity, disability, and global impression of recovery were obtained by a blinded assessor at baseline and at follow-up appointments at 2, 4, and 6 months after randomization.

Results

There were no significant between-group differences for the primary outcomes of pain intensity at 2 months (mean difference = 0.05, 95% CI = –0.90 to 0.80) and disability at 2 months (mean difference = 0.00, 95% CI = –1.55 to 1.56). There also were no statistically significant differences between treatment groups for any of the secondary outcome measures.

Limitations

Participants and physical therapists were not masked.

Conclusions

People with chronic LBP had similar improvements in pain, disability, and global impression of recovery with treatment consisting of symptom-guided stretching and strengthening exercises and treatment based on the MSI model.

Optimizing Cognitive Function in Persons With Chronic Pain

OBJECTIVES

Cognitive functioning is commonly disrupted in people living with chronic pain, yet it is an aspect of pain that is often not routinely assessed in pain management settings, and there is a paucity of research on treatments or strategies to alleviate the problem. The purpose of this review is to outline recent research on cognitive deficits seen in chronic pain, to give an overview of the mechanisms involved, advocate cognitive functioning as an important target for treatment in pain populations, and discuss ways in which it may be assessed and potentially remediated.

METHODS

A narrative review.

RESULTS

There are several options for remediation, including compensatory, restorative, and neuromodulatory approaches to directly modify cognitive functioning, as well as physical, psychological, and medication optimization methods to target secondary factors (mood, sleep, and medications) that may interfere with cognition.

DISCUSSION

We highlight the potential to enhance cognitive functions and identify the major gaps in the research literature.