Non-specific low back pain

Development of 2-D and 3-D culture platforms derived from decellularized nucleus pulposus

Bioscaffolds derived from the extracellular matrix (ECM) have shown the capacity to promote regeneration by providing tissue-specific biological instructive cues that can enhance cell survival and direct lineage-specific differentiation. This study focused on the development and characterization of two-dimensional (2-D) and three-dimensional (3-D) cell culture platforms incorporating decellularized nucleus pulposus (DNP). First, a detergent-free protocol was developed for decellularizing bovine nucleus pulposus (NP) tissues that was effective at removing cellular content while preserving key ECM constituents including collagens, glycosaminoglycans, and the cell-adhesive glycoproteins laminin and fibronectin. Next, novel 2-D coatings were generated using the DNP or commercially-sourced bovine collagen type I (COL) as a non-tissue-specific control. In addition, cryo-milled DNP or COL particles were incorporated within methacrylated chondroitin sulphate (MCS) hydrogels as a 3-D cell culture platform for exploring the effects of ECM particle composition. Culture studies showed that the 2-D coatings derived from the DNP could support cell attachment and growth, but did not maintain or rescue the phenotype of primary bovine NP cells, which de-differentiated when serially passaged in monolayer culture. Similarly, while bovine NP cells remained highly viable following encapsulation and 14 days of culture within the hydrogel composites, the incorporation of DNP particles within the MCS hydrogels was insufficient to maintain or rescue changes in NP phenotype associated with extended in vitro culture based on gene expression patterns. Overall, DNP produced with our new decellularization protocol was successfully applied to generate both 2-D and 3-D bioscaffolds; however, further studies are required to assess if these platforms can be combined with additional components of the endogenous NP microenvironment to stimulate regeneration or lineage-specific cell differentiation.

Low back pain in the Bangladeshi adult population: a cross-sectional national survey

OBJECTIVE

Low back pain (LBP) is a common musculoskeletal disorder. This study aims to determine the residence-specific and sex-specific prevalence and the factors associated with LBP in Bangladesh.

METHODS

The study subjects (aged ≥18 years) were identified from 20 primary sampling units of the national census following a cross-sectional multistage stratified sampling design. We considered the mechanical type of LBP for this study. A Bangla version of the modified Community Oriented Programme for Control of Rheumatic Disorders questionnaire was used. A team of trained field workers, rheumatology residents and rheumatologists collected the data. Analysis was done using weighted data.

RESULTS

Two thousand subjects were approached, but 1843 could be screened. Among them, 561 had musculoskeletal disorders, and 343 were diagnosed with LBP. The weighted prevalence of LBP was 18.5% (95% CI: 11.8% to 25.2%) and age-standardised prevalence of LBP was 19.4% (95% CI: 14.0% to 24.8%), which was higher in women (27.2%, 19.3% to 35.1%) than men (14.0%, 8.7% to 19.3%). The prevalence persistently increased from age group 18-34 years (10.5%, 5.7 to 15.4) to ≥55 years (27.8%, 16.1% to 39.5%). People with no education had the highest prevalence (31.3%, 22.3% to 40.4%). The prevalence did not differ between urban and rural residential locations. Four factors were significantly associated with LBP: age (adjusted odds ratio: 2.4, 95% CI: 1.7 to 3.4), female sex (2.2, 1.5 to 3.3), absence of formal education (2.3, 1.6 to 3.3) and hypertension (1.7, 1.1 to 2.6).

CONCLUSION

LBP is a common problem in Bangladeshi adults. The factors identified are age, female sex, no formal education and hypertension. These should be addressed adequately to prevent and treat LBP.

Low back pain and its determinants among wait staff in Gondar town, North West Ethiopia: A cross-sectional study

Background

Low back pain is a common public health issue in the working population and one of the leading causes of disability. It is the leading cause of work-related conditions and the most common reason for filing a workers' compensation claim in low- and middle-income countries. Ethiopia is a developing country; there is a shortage of working materials, skilled labor, and a lack of awareness of ergonomics posture, which lead to lifting heavy objects, long periods of standing, repetitive twisting, and same sustained posture for long periods of time without a shift. As a result, the purpose of this study was to assess the prevalence and associated factors of work-related low back pain among restaurant wait staff in Gondar, Ethiopia, in the year 2019.

Methods

Institution-based cross-sectional study, including 420 restaurant wait personnel, was undertaken from 1 March to 30 April 2019. A simple random sampling procedure was used to choose the restaurants and wait staff. A standardized Nordic questionnaire was used to collect data. Data were entered into Epi Info 7 and analyzed in SPSS version 20. The univariate and multivariate logistic regression analyses were calculated. The significance of associations was reported by a P-value of < 0.05 and an adjusted odds ratio (AOR). The model fitness checked by the Hosmer–Lemeshow goodness of fit test was used.

Result

In this study, a total of 420 participants (99.53% response rate) ranging in age from 17 to 53 years old participated, with 184 (43.8%) participants reporting low back pain at some point in the past 12 months. Female participants had a higher prevalence of 130 (70.6%). Sex (AOR = 2.98; 95% CI: 1.07–8.30), frequent exercise (AOR 0.47; 95% CI: 0.24, 0.93), extended standing (AOR 8.82; 95% CI: 3.30, 20.32], and repetitive tasks (AOR 7.49; 95% CI: 4.29, 13.19) were all found to be significant predictors in low back pain.

Conclusion

More than two-fifth of waitresses and waiters reported low back discomfort at some point in the past 12 months. Predisposing factors for low back discomfort among restaurant wait staff included being female, standing for long periods of time while serving, and performing repetitive tasks. Regular exercise was found to be a protective factor against low back pain in wait staff. Delivering ongoing safety training is among the most potent essential measures required in preventing low back pain.

In vivo measurement of intradiscal pressure changes related to thrust and non-thrust spinal manipulation in an animal model: a pilot study

BACKGROUND

The intervertebral disc is a known back pain generator and is frequently the focus of spinal manipulative therapy evaluation and treatment. The majority of our current knowledge regarding intradiscal pressure (IDP) changes related to spinal manual therapy involves cadaveric studies with their inherent limitations. Additional in vivo animal models are needed to investigate intervertebral disc physiological and molecular mechanisms related to spinal manipulation and spinal mobilization treatment for low back disorders.

METHODS

Miniature pressure catheters (Millar SPR-1000) were inserted into either the L4-L5 or L5-L6 intervertebral disc of 3 deeply anesthetized adult cats (Oct 2012-May 2013). Changes in IDP were recorded during delivery of instrument-assisted spinal manipulation (Activator V® and Pulstar®) and motorized spinal flexion with/without manual spinous process contact.

RESULTS

Motorized flexion of 30° without spinous contact decreased IDP of the L4-L5 disc by ~ 2.9 kPa, while physical contact of the L4 spinous process decreased IDP an additional ~ 1.4 kPa. Motorized flexion of 25° with L5 physical contact in a separate animal decreased IDP of the L5-L6 disc by ~ 1.0 kPa. Pulstar® impulses (setting 1-3) increased IDP of L4-L5 and L5-L6 intervertebral discs by ~ 2.5 to 3.0 kPa. Activator V® (setting 1-4) impulses increased L4-L5 IDP to a similar degree. Net changes in IDP amplitudes remained fairly consistent across settings on both devices regardless of device setting suggesting that viscoelastic properties of in vivo spinal tissues greatly dampen superficially applied manipulative forces prior to reaching deep back structures such as the intervertebral disc.

CONCLUSIONS

This study marks the first time that feline in vivo changes in IDP have been reported using clinically available instrument-assisted spinal manipulation devices and/or spinal mobilization procedures. The results of this pilot study indicate that a feline model can be used to investigate IDP changes related to spinal manual therapy mechanisms as well as the diminution of these spinal manipulative forces due to viscoelastic properties of the surrounding spinal tissues. Additional investigation of IDP changes is warranted in this and/or other in vivo animal models to provide better insights into the physiological effects and mechanisms of spinal manual therapy at the intervertebral disc level.

Advanced Manual Therapy Approach for Management of Non-specific Low Back Pain- a Case Report

The lower back is a complex area, with joints having a very limited range of motion and vast muscular activity. Low back pain is common, and its management depends upon the pain generators. There are various treatment options available, depending on the cause of the pain. In this case, a medical student with pain on a scale of 8/10 on activity came to the physiotherapy department for rehabilitation and pain relief. Her low back pain was chronic and non-specific. The aim of rehabilitation was to reduce the pain and make the patient pain-free. An integrated neuromuscular inhibition technique (INIT), along with a conventional physiotherapy approach, was given to the patient. The integrated neuromuscular inhibition technique can be used to reduce lower back pain and functional disability. After physiotherapy rehabilitation, the range of lumbar flexion improved. In patients presenting with low back pain, early physiotherapy should be started to maintain strength, reduce pain, and reduce functional disability.

The WATER study: Which AquaTic ExeRcises increase muscle activity and limit pain for people with low back pain?

OBJECTIVE

Aquatic exercise therapy is used for the treatment and management of chronic low back pain (CLBP). However, to the authors' knowledge, no studies to date have compared muscle activity between different aquatic exercises performed by people with CLBP. As such, this study assessed and compared muscle activity, pain, perceived exertion and exercise intensity between different rehabilitative aquatic exercises.

DESIGN

Cross-sectional.

SETTING

A 25-m indoor swimming pool within a university building.

PARTICIPANTS

Twenty participants with non-specific CLBP.

ASSESSMENT

Twenty-six aquatic exercises in shallow water (1.25-m depth). Muscle activity was quantified bilaterally for the erector spinae, multifidus, gluteus maximus and medius, rectus abdominis, and external and internal obliques.

MAIN OUTCOMES

Mean and peak muscle activity, pain (visual analogue scale), perceived exertion (Borg scale) and exercise intensity (heart rate).

RESULTS

Hip abduction/adduction and extension/flexion exercises produced higher activity for gluteal muscles. Variations of squat exercises increased the activity of back extensors. Higher abdominal muscle activity was produced with exercises that made use of buoyancy equipment and included leg and trunk movements while floating on the back, and with some proprioceptive and dynamic lower limb exercises. Pain occurrence and intensity were very low, with 17 exercises being pain free.

CONCLUSIONS

This study provides evidence on trunk and gluteal muscle activity, pain, intensity and perceived exertion for people with CLBP performing aquatic exercises. The findings may be useful when prescribing exercises for rehabilitation, as physiotherapists seek to implement progression in effort and muscle activity, variation in exercise type, and may wish to target or avoid particular muscles. CONTRIBUTION OF THE PAPER.

Evaluating Different Measures of Low Back Pain Among U.S. Manual Materials Handling Workers: Comparisons of Demographic, Psychosocial, and Job Physical Exposure

OBJECTIVE

To examine differences in demographic, psychosocial, and job physical exposure risk factors between multiple low back pain (LBP) outcomes in a prospective cohort of industrial workers.

BACKGROUND

LBP remains a leading cause of lost industrial productivity. Different case definitions involving pain (general LBP), medication use (M-LBP), seeking healthcare (H-LBP), and lost time (L-LBP) are often used to study LBP outcomes. However, the relationship between these outcomes remains unclear.

METHOD

Demographic, health status, psychosocial, and job physical exposure risk factors were quantified for 635 incident-eligible industrial workers. Incident cases of LBP outcomes and pain symptoms were quantified and compared across the four outcomes.

RESULTS

Differences in age, gender, medical history, and LBP history were found between the four outcomes. Most incident-eligible workers (67%) suffered an LBP outcome during follow-up. Cases decreased from 420 for LBP (25.4 cases/100 person-years) to 303 for M-LBP (22.0 cases/100 person-years), to 151 for H-LBP (15.6 cases/100 person-years), and finally to 56 for L-LBP (8.7 cases/100 person-years). Conversely, pain intensity and duration increased from LBP to H-LBP. However, pain duration was relatively lower for L-LBP than for H-LBP.

CONCLUSION

Patterns of cases, pain intensity, and pain duration suggest the influence of the four outcomes. However, few differences in apparent risk factors were observed between the outcomes. Further research is needed to establish consistent case definitions.

APPLICATION

Knowledge of patterns between different LBP outcomes can improve interpretation of research and guide future research and intervention studies in industry.

Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression in patients with chronic low back pain

Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status, and depression in patients with chronic low back pain (LBP).

Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years). Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and at the first and 12th weeks after treatment.

Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores, the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week.

Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility, and functional status in patients with chronic LBP.

Spinal degeneration is associated with lumbar multifidus morphology in secondary care patients with low back or leg pain

Associations between multifidus muscle morphology and degenerative pathologies have been implied in patients with non-specific low back pain, but it is unknown how these are influenced by pathology severity, number, or distribution. MRI measures of pure multifidus muscle cross-sectional area (CSA) were acquired from 522 patients presenting with low back and/or leg symptoms in an outpatient clinic. We explored cross-sectional associations between the presence, distribution, and/or severity of lumbar degenerative pathologies (individually and in aggregate) and muscle outcomes in multivariable analyses (beta coefficients [95% CI]). We identified associations between lower pure multifidus muscle CSA and disc degeneration (at two or more levels): − 4.51 [− 6.72; − 2.3], Modic 2 changes: − 4.06 [− 6.09; − 2.04], endplate defects: − 2.74 [− 4.58; − 0.91], facet arthrosis: − 4.02 [− 6.26; − 1.78], disc herniations: − 3.66 [− 5.8; − 1.52], and when > 5 pathologies were present: − 6.77 [− 9.76; − 3.77], with the last supporting a potential dose–response relationship between number of spinal pathologies and multifidus morphology. Our findings could hypothetically indicate that these spinal and muscle findings: (1) are part of the same degenerative process, (2) result from prior injury or other common antecedent events, or (3) have a directional relationship. Future longitudinal studies are needed to further examine the complex nature of these relationships.

Structural, Functional and Neurochemical Cortical Brain Changes Associated with Chronic Low Back Pain

Chronic low back pain (CLBP) is one of the most prevalent musculoskeletal disorders, being one of the leading contributors to disability worldwide and involving an important economic and social burden. Up to 90% of CLBP is non-specific (not associated with specific injuries), with a chronicity expectation estimated at 10%. Currently, motivational and emotional central circuits are being investigated due to their role in CLBP persistency and chronification. Therefore, this narrative review aimed to summarize the evidence regarding the cortical brain changes described for proposing novel multidisciplinary approaches. Novel advances in neuroimaging techniques demonstrated structural (e.g., decrease in the grey matter located at the dorsolateral prefrontal cortex), functional (e.g., connectivity impairments in those areas involved in pain processing), and neurochemical changes (e.g., decrease in cerebral metabolites). In addition, significant changes were found in the primary somatosensory and motor cortex, contributing to the alteration of low back muscles activation and function.

Low test–retest reliability of a protocol for assessing somatosensory cortex excitability generated from sensory nerves of the lower back

In people with chronic low back pain (CLBP), maladaptive structural and functional changes on a cortical level have been identified. On a functional level, somatosensory cortical excitability has been shown to be reduced in chronic pain conditions, resulting in cortical disinhibition. The occurrence of structural and/or functional maladaptive cortical changes in people with CLBP could play a role in maintaining the pain. There is currently no measurement protocol for cortical excitability that employs stimulation directly to the lower back. We developed a protocol for the measurement of single pulse somatosensory evoked potential (SEP) waveforms and paired-pulse behavior (PPB) generated from sensory nerves of the lower back and quantified its test–retest reliability in a sample of 30 healthy individuals to gain insights into the normal variability of cortical responses, which could then be compared to results from people with CLBP. We investigated cortical excitability by measuring SEPs and PPB. PPB was defined as the ratio of the amplitude of the second cortical response (A2s) divided by the first cortical response (A1). A2s was determined by subtracting the response to single-pulse stimuli from the paired pulse stimuli response to account for linear superposition effects. The test–retest reliability of the protocol was very poor with no evidence of systematic bias but a high amount of random variability between sessions. There was no significant difference in the right side PPB for session 1 (Mean ratio A2s/A1 = 0.66, SD = 0.54) and session 2 (Mean ratio A2s/A1 = 0.94, SD = 1.56); mean session difference [(95% CI) = −0.44 (−1.23 to 0.34); t (22) = −1.17, p = 0.26]. The ICC₃.₁ (absolute agreement) for the outlier-removed right side PPB were 0.19 (95% CI: −0.84 to 0.66) and 0.43 for left side PPB (95% CI: −0.37 to 0.76). This finding potentially has wider implications for PPB protocols. If these findings were replicated in other groups and other nerves, it would question the validity of this measure more generally. However, these findings are restricted to healthy people and sensory nerves of the lower back and may not be generalizable.

Effect of exercise intervention on social distance in middle-aged and elderly patients with chronic low back pain

Background

Increased social distance is one of the manifestations of social impairment. Chronic low back pain (CLBP) is one of factors associated with increased social distance and social withdrawal. Exercise therapy is an effective means to social impairment. However, whether exercise could reduce social distance in patients with CLBP remains unknown. This study aimed to investigate the effect of exercise on social distance in middle-aged and elderly patients with CLBP.

Methods

The longitudinal intervention recruited 29 middle-aged and elderly patients with CLBP from various communities in Yangpu District, Shanghai, China. The participants received exercise intervention for 8 weeks. The assessments were conducted before and after the intervention, including social distance, pain intensity, unpleasantness of pain, Roland-Morris Questionnaire (RMDQ), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS). Intention to treat analysis was performed.

Results

After the 8-week exercise intervention, the social distance of patients with CLBP was shorter than that before intervention and showed significant difference (p &lt; 0.05). The scores of pain intensity, unpleasantness of pain, RMDQ, SAS, and SDS also decreased and were significantly different between pre- and post-intervention (p &lt; 0.05). In addition, the social distance, pain intensity, unpleasantness of pain, RMDQ, SAS, and SDS scores of the moderate CLBP group decreased more after the intervention compared with those of the mild CLBP group.

Conclusion

The 8-week exercise intervention cannot only shorten the social distance in middle-aged and elderly patients with CLBP but also relieve pain, disability, and negative emotions.

A Review on Treatment Approaches for Chronic Low Back Pain via Mulligans Movement With Mobilization and Physical Therapy

Low back pain is a leading cause of functional disability. Low back pain is a problem that every one of all age groups faces and there are various methods used to correct low back pain. Manual therapy is a specialized area in physiotherapy which manages neuromuscular pain. Manual therapy techniques include the Maitland mobilization technique, Kaltenborn mobilization technique, Mulligan technique, Active release technique, and many more. Manual therapy mainly works on arthrokinematics and osteokinematics of the joint. It is one of the main strategies used to manage low back pain. Low back pain can be because by spinal dysfunction, Sacroiliac dysfunction, muscle pathology, or any ligamentous strain. The cause of the low back pain should be identified and treated accordingly. Articles using keywords - chronic low back pain, Mulligan, and non-specific low back pain were searched on the database of Pubmed and Scopus a total of 30 articles from the timeframe of 2011 to 2021 were included in the study. From this review, we can conclude that Mulligan mobilization with movement is an effective way to reduce low back pain. Further studies need to be conducted to check the effectiveness of manual therapy techniques in chronic low back pain.

Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review

Low back pain (LBP) is a global and disabling problem. A considerable number of systematic reviews published over the past decade have reported a range of factors that increase the risk of chronicity due to LBP. This study summarizes up-to-date and high-level research evidence on the biopsychosocial prognostic factors of outcomes in adults with non-specific low back pain at follow-up. An umbrella review was carried out. PubMed, the Cochrane Database of Systematic Reviews, Web of Science, PsycINFO, CINAHL Plus and PEDro were searched for studies published between 1 January 2008 and 20 March 2020. Two reviewers independently screened abstracts and full texts, extracted data and assessed review quality. Fifteen systematic reviews met the eligibility criteria; all were deemed reliable according to our criteria. There were five prognostic factors with consistent evidence of association with poor acute-subacute LBP outcomes in the long term (high levels of pain intensity and disability, high emotional distress, negative recovery expectations and high physical demands at work), as well as one factor with consistent evidence of no association (low education levels). For mixed-duration LBP, there was one predictor consistently associated with poor outcomes in the long term (high pain catastrophism). We observed insufficient evidence to synthesize social factors as well as to fully assess predictors in the chronic phase of LBP. This study provides consistent evidence of the predictive value of biological and psychological factors for LBP outcomes in the long term. The identified prognostic factors should be considered for inclusion into low back pain explanatory models.

Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain Within Physical Therapy: A Practical Guide for the Implementation of an Integrated Approach

Most people who have nonspecific chronic spinal pain (nCSP) report comorbid insomnia. However, in current treatment strategies for nCSP, insomnia is usually not addressed. Considering the bidirectional interaction between pain and sleep and its underlying psychophysiological mechanisms, insomnia may increase the risk of developing adverse physical and psychological health outcomes and should thus no longer be left untreated. As suggested by previous pilot studies, adding cognitive behavioral therapy for insomnia to the contemporary evidence-based biopsychosocial physical therapy approach may also improve pain outcomes in nCSP. This manuscript aims to provide practical guidelines on hybrid physical therapy, including the combination of the following components: (1) pain neuroscience education (eg, to reconceptualize pain) and cognition-targeted exercise therapy (eg, graded exposure to functional daily life movements), and (2) cognitive behavioral therapy for insomnia (sleep psychoeducation, behavioral and cognitive therapy, correction of sleep hygiene, and relaxation therapy) can be deployed for the management of patients who have chronic spinal pain. Impact. Due to the major impact sleep disturbances have on pain and disability, insomnia as a comorbidity should no longer be ignored when treating patients with chronic spinal pain.

An Evaluation of an Innovative Exercise to Relieve Chronic Low Back Pain in Sedentary Workers

OBJECTIVE

The purpose of the study was to examine the effectiveness of a novel supported dynamic lumbar extension with the abdominal drawing-in maneuver (ADIM) technique on stature change, deep abdominal muscle activity, trunk muscle fatigue, and pain intensity during prolonged sitting in chronic low back pain (CLBP) participants.

BACKGROUND

Prolonged sitting can cause trunk muscle fatigue from continuous contraction of deep trunk muscles in seated postures. Deficiency of activity of deep muscles can reduce muscular support of the spine, causing stress on spinal structures, which could result in pain.

METHOD

Thirty participants with CLBP were randomly allocated: (a) control-sitting without exercise, and (b) intervention-supported dynamic lumbar extension with the ADIM technique.

RESULTS

Compared to the intervention condition, the control condition demonstrated significantly greater deterioration in stature change, increased levels of deep trunk muscle fatigue, and an increase in pain during prolonged sitting.

CONCLUSION

The supported dynamic lumbar extension with the ADIM technique appears to provide a protective effect on detrimental stature change and deep trunk muscle fatigue. In addition, it prevented an increase in pain intensity during prolonged sitting in people with CLBP.

APPLICATION

Sedentary behavior harms health, particularly affecting the lower back. Clinicians can use the intervention to induce dynamic lumbar movement, and this exercise can maintain deep trunk muscle activity during prolonged sitting, thereby helping to prevent low back pain (LBP) problems.

Quantitative 23 Na-MRI of the intervertebral disk at 3 T

Monitoring the tissue sodium content (TSC) in the intervertebral disk geometry noninvasively by MRI is a sensitive measure to estimate changes in the proteoglycan content of the intervertebral disk, which is a biomarker of degenerative disk disease (DDD) and of lumbar back pain (LBP). However, application of quantitative sodium concentration measurements in ²³ Na-MRI is highly challenging due to the lower in vivo concentrations and smaller gyromagnetic ratio, ultimately yielding much smaller signal relative to ¹ H-MRI. Moreover, imaging the intervertebral disk geometry imposes higher demands, mainly because the necessary RF volume coils produce highly inhomogeneous transmit field patterns. For an accurate absolute quantification of TSC in the intervertebral disks, the B1 field variations have to be mitigated. In this study, we report for the first time quantitative sodium concentration in the intervertebral disks at clinical field strengths (3 T) by deploying ²³ Na-MRI in healthy human subjects. The sodium B1 maps were calculated by using the double-angle method and a double-tuned (¹ H/²³ Na) transceive chest coil, and the individual effects of the variation in the B1 field patterns in tissue sodium quantification were calculated. Phantom measurements were conducted to evaluate the quality of the Na-weighted images and B1 mapping. Depending on the disk position, the sodium concentration was calculated as 161.6 mmol/L-347 mmol/L, and the mean sodium concentration of the intervertebral disks varies between 254.6 ± 54 mmol/L and 290.1 ± 39 mmol/L. A smoothing effect of the B1 correction on the sodium concentration maps was observed, such that the standard deviation of the mean sodium concentration was significantly reduced with B1 mitigation. The results of this work provide an improved integration of quantitative ²³ Na-MRI into clinical studies in intervertebral disks such as degenerative disk disease and establish alternative scoring schemes to existing morphological scoring such as the Pfirrmann score.

Clinical Studies of Bee Venom Acupuncture for Lower Back Pain in the Korean Literature

This study aimed to identify all of the characteristics of bee venom acupuncture (BVA) for the treatment of lower back pain (LBP) that are described in the Korean literature, and to provide English-speaking researchers with bibliometrics. Six Korean electronic databases and sixteen Korean journals on BVA treatment for back pain were searched up to February 2022. This report included and analyzed 64 clinical studies on BVA interventions for back pain and 1297 patients with LBP. The most common disease in patients with back pain was lumbar herniated intervertebral discs (HIVD) of the lumbar spine (L-spine). All studies used bee venom (BV) diluted with distilled water. The concentration of BVA for HIVD of L-spine patients with LBP ranged from 0.01 to 5.0 mg/mL; the dosage per treatment was 0.02–2.0 mL, and for a total session was 0.3–40.0 mL. The most used outcome measure was the visual analogue scale for back pain (n = 45, 70.3%), and most of the papers reported that each outcome measure had a positive effect. Korean clinical studies were typically omitted from the review research, resulting in potential language bias. This study provides clinical cases in Korea for future development and standardization of BVA treatment for back pain.

Kinesiophobia and associated factors among patients with chronic non-specific low back pain

PURPOSE

This study determined the association between kinesiophobia and age, body mass index, highest educational status, self-efficacy, pain intensity, and disability in chronic non-specific low back pain (CNSLBP) patients. Predictors of kinesiophobia were also assessed.

METHODS

This cross-sectional design utilised 224 CNSLBP patients in tertiary hospitals in Nigeria. The Tampa Scale of Kinesiophobia, Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and Numerical Pain Rating Scale were used to assess kinesiophobia, disability, self-efficacy, and pain intensity respectively. Spearman's correlation and multiple regression analysis determined the association between the variables of interest and the predictors of kinesiophobia, respectively.

RESULTS

Most of the participants reported a high level of kinesiophobia (92%), low level of self-efficacy (68.8%), moderate pain intensity (58.0%), and moderate disability (57.1%). A significant positive weak correlation was observed between kinesiophobia and pain intensity (r = 0.138, p = 0.040). Gender, self-efficacy, pain intensity, and disability significantly predicted the extent of kinesiophobia (p < 0.05).

CONCLUSION

The increased levels of kinesiophobia are a cause for concern and highlight the need for kinesiophobia and related factors to be closely monitored and incorporated into preventive and curative rehabilitation programmes for CNSLBP patients to minimise the negative impact on rehabilitation outcomes.Implications for RehabilitationPatients with chronic non-specific low back pain (CNSLBP) have high levels of kinesiophobia, which could predispose them to avoidance behaviours, physical inactivity, and deterioration of health, all of which, if not addressed, may result in poor rehabilitation outcomes, setting off a viscious cycle.Regular kinesiophobia assessments could indicate areas of rehabilitation concern, allowing health care providers to better target rehabilitation programs and improve rehabilitation outcomes.Pain severity, self-efficacy, and disability should be frequently assessed and included when planning rehabilitation programs, to reduce the detrimental impact on kinesiophobia.In patients with CNSLBP, graded exposure therapy to movement is necessary to prevent and reduce kinesiophobia, thereby increasing compliance during rehabilitation programs.

Trunk muscle function and its association with functional limitations in sedentary occupation workers with and without chronic nonspecific low back pain

BACKGROUND

The function of trunk muscles in chronic nonspecific low back pain (CNLBP) is controversially discussed, and trunk muscle function in sedentary occupation workers is poorly understood.

OBJECTIVE

To investigate whether muscle function differs between sedentary occupation workers with and without CNLBP and to determine the association between functional limitations and muscle function.

METHODS

This study included 32 sedentary occupation workers (16 workers with CNLBP and 16 age- and sex-matched workers without CNLBP). Group differences in isokinetic trunk flexion-extension strength, muscle cocontraction, endurance time (Biering-Sorensen test) and electromyographic muscle fatigue were assessed. The association of these parameters and Oswestry Disability Index (ODI) score were examined in the CNLBP group.

RESULTS

Participants with CNLBP had lower trunk extensor (-20%) and flexor (-18%) strength and less cocontraction (-22%) than participants without CNLBP, but due to large variability in both groups these differences were not statistically significant. Trunk muscle endurance and fatigue were comparable between groups. Variance in endurance time explained 28% of variance in the ODI-score in the CNLBP group (R2= 0.277).

CONCLUSIONS

In patients with CNLBP, greater functional disability was associated with lower endurance. Further evidence is necessary to elucidate whether specifically training endurance performance may be beneficial for sedentary occupation workers.

Chronic non-specific low back pain and ankle proprioceptive acuity in community-dwelling older adults

BACKGROUND

For people above 65 years old, low-back pain (LBP) is associated with balance problems and falls. Down-weighting of proprioception due to ageing and LBP may cause such balance problems. While lumbar proprioceptive deficits have been shown in LBP and indications for more generalized deficits have been found, ankle proprioception, which is crucial for balance control, has not been studied in people with LBP.

RESEARCH QUESTION

Is there any difference in ankle proprioceptive acuity between community-dwelling older adults with and without LBP? We hypothesized that ankle proprioception was impaired in community-dwelling older adults with LBP compared to those without LBP.

METHODS

Thirty participants over 65 years old volunteered. Fifteen had LBP (M/F = 2/13, age = 72.0 (4.6) years), fifteen were healthy controls without back pain (control group) (M/F = 2/13, age = 72.1 (4.8) years). Ankle proprioception was measured in normal weight-bearing conditions, using the Active Movement Extent Discrimination Apparatus (AMEDA). Accuracy on the ankle proprioceptive test was expressed as absolute error (AE), constant error (CE) and variable error (VE).

RESULTS

AE was significantly larger (P = 0.029, 95 % CI = [0.00, 0.90]) in the LBP group, CE was also significantly larger (P = 0.046, 95 % CI = [-0.91, -0.01]), indicating an underestimation of ankle inversion in participants with LBP compared to controls. VE was not different between the two groups (P = 0.520, 95 % CI = [-0.20, 0.59]). No significant correlation was found between pain intensity and AE, CE or VE (P > 0.05).

CONCLUSION

Ankle proprioception decreased in older people with LBP compared to healthy peers, suggesting impaired central proprioceptive processing. Older people with LBP underestimate the extent of ankle inversion, which may increase fall risk. Thus, evaluation and training of ankle proprioception may be useful in older people with LBP.

Natural language processing in low back pain and spine diseases: A systematic review

Natural Language Processing (NLP) is a discipline at the intersection between Computer Science (CS), Artificial Intelligence (AI), and Linguistics that leverages unstructured human-interpretable (natural) language text. In recent years, it gained momentum also in health-related applications and research. Although preliminary, studies concerning Low Back Pain (LBP) and other related spine disorders with relevant applications of NLP methodologies have been reported in the literature over the last few years. It motivated us to systematically review the literature comprised of two major public databases, PubMed and Scopus. To do so, we first formulated our research question following the PICO guidelines. Then, we followed a PRISMA-like protocol by performing a search query including terminologies of both technical (e.g., natural language and computational linguistics) and clinical (e.g., lumbar and spine surgery) domains. We collected 221 non-duplicated studies, 16 of which were eligible for our analysis. In this work, we present these studies divided into sub-categories, from both tasks and exploited models’ points of view. Furthermore, we report a detailed description of techniques used to extract and process textual features and the several evaluation metrics used to assess the performance of the NLP models. However, what is clear from our analysis is that additional studies on larger datasets are needed to better define the role of NLP in the care of patients with spinal disorders.

A feasibility study on yoga's mechanism of action for chronic low back pain: psychological and neurophysiological changes, including global gene expression and DNA methylation, following a yoga intervention for chronic low back pain

INTRODUCTION

Yoga has been shown to reduce pain and improve function in populations with chronic low back pain (cLBP), yet the underlying molecular mechanisms remain elusive. This study examined the feasibility and acceptability of a yoga research protocol, including recruitment, retention, and data collection, and investigated the preliminary effects of yoga on psychological and neurophysiological functions, including gene expression and DNA methylation profiles, in participants with cLBP.

METHODS

A one-arm trial was conducted with 11 participants with cLBP who enrolled in a 12-week yoga intervention. Data on subjective pain characteristics, quantitative sensory testing, and blood for analysis of differentially expressed genes and CpG methylation was collected prior to the start of the intervention and at study completion.

RESULTS

Based on pre-determined feasibility and acceptability criteria, the yoga intervention was found to be feasible and highly acceptable to participants. There was a reduction in pain severity, interference, and mechanical pain sensitivity post-yoga and an increase in emotion regulation and self-efficacy. No adverse reactions were reported. Differential expression analysis demonstrated that the yoga intervention induced increased expression of antisense genes, some of which serve as antisense to known pain genes. In addition, there were 33 differentially hypomethylated positions after yoga (log2 fold change ≥ 1), with enrichment of genes involved in NIK/NF-kB signaling, a major pathway that modulates immune function and inflammation.

DISCUSSION/CONCLUSIONS

The study supports the feasibility and acceptability of the proposed protocol to test a specific mechanism of action for yoga in individuals with cLBP. These results also support the notion that yoga may operate through our identified psychological and neurophysiologic pathways to influence reduced pain severity and interference.

Effects of a supervised exercise program in addition to electrical stimulation or kinesio taping in low back pain: a randomized controlled trial

Chronic low back pain it is one of the most common health problems worldwide. Usually is accompanied by a complex set of symptoms and generates significant direct and indirect socioeconomic and health costs. From a therapeutic point of view, there are a wide variety of methods to address the treatment of this pathology, however, these therapies have not been shown definitive efficacy. To investigate the effect of a mixed treatment with exercise and electrical stimulation versus exercise and kinesio taping in patients with non-specific chronic low back pain. A total of 58 patients participated in this single-blinded randomised clinical trial. Participants were assigned to the exercises- kinesio taping group, or exercises- analgesic current group, both received 12 treatment sessions. Disability, fear of movement, anxiety, depression, sleeps quality, pain, lower limb mechanosensitivity and pressure-pain thresholds were recorded at baseline and after 4 weeks of treatment. The 2 × 2 mixed analysis of covariance test showed statistically significant differences between groups for pain (P = 0.046). Pair-wise comparisons with baseline demonstrated significant differences for both groups in pain (P ≤ 0.001), disability (P ≤ 0.001), pressure-pain thresholds (P ≤ 0.044), lower limb mechanosensitivity, (P ≤ 0.047), anxiety (P ≤ 0.001), depression (P ≤ 0.001) and sleep quality (P ≤ 0.010). Patients with chronic low back pain who received a combined treatment of exercises and kinesio taping or analgesic current showed an improvement in pain, disability, anxiety, depression and sleep pattern. Moreover, exercises combined with electrotherapy produces greater improvements over these variables.

Trial registration: NCT02812459.

Microscopic changes in the spinal extensor musculature in people with chronic spinal pain: a systematic review

BACKGROUND CONTEXT

Chronic spinal pain is one the most common musculoskeletal disorders. Previous studies have observed microscopic structural changes in the spinal extensor muscles in people with chronic spinal pain. This systematic review synthesizes and analyzes all the existing evidence of muscle microscopic changes in people with chronic spinal pain.

PURPOSE

To assess the microscopy of spinal extensor muscles including the fiber type composition, the area occupied by fiber types, fiber size/cross sectional area (CSA), and narrow diameter (ND) in people with and without chronic spinal pain. Further, to compare these outcome measures across different regions of the spine in people with chronic neck, thoracic and low back pain.

STUDY DESIGN

Systematic review with meta-analysis.

METHODS

MEDLINE (Ovid Interface), Embase, PubMed, CINAHL Plus, and Web of Science were searched from inception to October 2020. Key journals, conference proceedings, grey literature and hand searching of reference lists from eligible studies were also searched. Two independent reviewers were involved in the selection process. Only studies examining the muscle microscopy of the spinal extensor muscles (erector spinae [ES] and/or multifidus [MF]) between people with and without chronic spinal pain were selected. The risk of bias from the studies was assessed using modified Newcastle Ottawa Scale and the level of evidence was established using the GRADE approach. Data were synthesized based on homogeneity on the methodology and outcome measures of the studies for ES and MF muscles and only four studies were eligible for analysis.

RESULTS

All the five studies included were related to chronic low back pain (CLBP). Meta-analysis (inverse variance method for random effect to calculate mean difference and 95% CI) was performed for the ES fiber type composition by numbers for both type I and type II fibers (I²=43% and 0% respectively indicating homogeneity of studies) and showed no difference between the people with and without CLBP with an overall effect estimate Z= 1.49 (p=.14) and Z=1.06 (p=.29) respectively. Meta-analysis was performed for ES fiber CSA for both type I and type II fibers (I²=0 for both) and showed no difference between people with and without CLBP with an overall effect estimate Z=0.08 (p=.43) and Z=0.75 (p=.45) respectively. Analysis was not performed for ES area occupied by fiber types and ND due to heterogeneity of studies and lack of evidence respectively. Similarly, meta-analysis was not performed for MF fiber type composition by numbers due to heterogeneity of studies. MF analysis for area occupied by fiber type, fiber CSA and ND did not yield sufficient evidence.

CONCLUSIONS

For the ES muscle, there was no difference in fiber type composition and fiber CSA between people with and without CLBP and no conclusions could be drawn for ND for the ES. For the MF, no conclusions could be drawn for any of the muscle microscopy outcome measures. Overall, the quality of evidence is very low and there is very low evidence that there are no differences in microscopic muscle features between people with and without CLBP.

Novel elemental grading system for radiographic lumbar spondylosis in a population based-cohort study of a Japanese mountain village

Purpose

Lumbar radiography is a primary screening tool for lumbar spondylosis (LS). Kellgren-Lawrence (KL) classification is widely used to evaluate LS; however, it cannot individually evaluate each radiographic feature. The purpose of this study was to 1) evaluate radiographic LS using a novel elemental grading system and 2) investigate the relationship between the grades of radiographic LS and low back pain (LBP) in a population-based cohort study.

Methods

A total of 260 (75 men, 185 women; mean age, 71.5 ± 8.7 years) participants were included in this study. Participants were divided into two groups according to the presence of LBP (LBP- and LBP+ groups). Radiographic features, including osteophyte (OP), disc height narrowing (DHN), vertebral sclerosis (VS), and spondylolisthesis (SL), were classified between grades of 0–2 grades according to the extent of radiographic changes. The sum of grades at each intervertebral level was designated as the intervertebral grade (IG).

Results

Intra- and inter-observer reliability (kappa coefficient) of OP, DHN, VS, and SL were 0.82–0.92. OP, DHN, VS, and IG grades were significantly higher in the LBP+ group than in the LBP- group. There were no significant differences in KL grades between the LBP- and LBP+ groups. Logistic regression analysis demonstrated that VS grade was a significant independent factor associated with LBP.

Conclusion

The novel elemental grading system of LS would reflect LBP more accurately than the KL classification by individually evaluating each radiographic feature.

Chromobox homolog 4 overexpression inhibits TNF-α-induced matrix catabolism and senescence by suppressing activation of the NF-κB signaling pathway in nucleus pulposus cells

Intervertebral disc degeneration (IDD) is featured as enhanced catabolism of extracellular matrix (ECM) in the nucleus pulposus (NP), in which tumor necrosis factor-alpha (TNF-α)-related cell senescence is involved. Chromobox homolog protein 4 (CBX4) exhibits anti-inflammatory effects and shows promising therapeutic potential. Thus, in the present study, we explore the role of CBX4 in IDD. Immunohistochemistry staining reveals that CBX4 expression is decreased in severe degenerative NP tissues compared to mild degenerative tissues, and real-time PCR and western blot analysis results show that CBX4 expression is downregulated under TNF-α stimulation in NP cells. siRNA and adenoviruses are used to knockdown or overexpress CBX4, respectively. The results demonstrate that CBX4 knockdown augments the catabolism of ECM in human NP cells, while CBX4 overexpression in rat NP cells restores the ECM degradation induced by TNF-α, as illustrated by immunofluorescence and western blot analysis. In addition, transcriptome sequencing results reveal the regulatory effect of CBX4 on the cell cycle, and further western blot analysis and senescence-associated β-galactosidase staining assay indicate that CBX4 overexpression alleviates cell senescence in the presence of TNF-α. Moreover, the phosphorylation of p65, which indicates the activation of NF-κB signaling, is measured by western blot analysis and immunofluorescence assay, and the results reveal that CBX4 overexpression reduces the TNF-α-induced increase in the p-p65/p65 ratio. In addition, the effect of CBX4 overexpression in NP cells is suppressed by NF-κB agonist. In summary, our results indicate that CBX4 overexpression can suppress TNF-α-induced matrix catabolism and cell senescence in the NP by inhibiting NF-κB activation. This study may provide new approaches for preventing and treating IDD.

Prevalence of symptomatic axial osteoarthritis phenotypes in Spain and associated socio-demographic, anthropometric, and lifestyle variables

OBJECTIVE

Axial osteoarthritis (OA) is a common cause of back and neck pain, however, few studies have examined its prevalence. The aim was to estimate the prevalence and the characteristics of symptomatic axial OA in Spain.

METHODS

EPISER2016 is a cross-sectional multicenter population-based study of people aged 40 years or older. Subjects were randomly selected using multistage stratified cluster sampling. Participants were contacted by telephone to complete rheumatic disease screening questionnaires. Two phenotypes were analyzed, patients with Non-exclusive axial OA (NEA-OA) and Exclusive axial OA (EA-OA). To calculate the prevalence and its 95% confidence interval (CI), the sample design was considered and weighting was calculated according to age, sex and geographic origin.

RESULTS

Prevalence of NEA-OA by clinical or clinical-radiographic criteria was 19.17% (95% CI: 17.82-20.59). The frequency of NEA-OA increased with age (being 3.6 times more likely in patients aged 80 s or more than in those between 40 and 49 years) and body mass index. It was significantly more frequent in women, as well as in the center of Spain. It was less frequent in those with a higher level of education. Lumbar OA was more frequent than cervical OA. This difference grew with increasing age and was not associated with gender. It was also greater in overweight and obese subjects.

CONCLUSIONS

This is the first study on the prevalence of axial OA phenotypes in Europe describing the associated socio-demographic, anthropometric, and lifestyle variables.

Effectiveness of whole-body vibration exercise and core stabilization exercise in chronic non-specific low back pain: A randomized-controlled study

Objectives

The aim of this study was to investigate the effectiveness of whole-body vibration exercise (WBVE) and core stabilization exercise (CSE) on pain, muscle strength, and functional recovery in patients with chronic non-specific low back pain (NLBP).

Patients and methods

Between June 2016 and July 2017, a total of 74 patients with NLBP (12 males, 62 females; mean age: 44.7±8.9 years; range, 24 to 64 years) were included in this prospective, randomized-controlled study. The patients were randomly assigned to WBVE group (WBVEG, n=25), CSE group (CSEG, (n=25), and home exercise group as the control group (CG, (n=24). All groups performed 24 sessions of exercise for a total of eight weeks. Clinical outcome was measured using the Visual Analog Scale (VAS), Roland-Morris Disability Questionnaire (RMDQ), computerized isokinetic muscle strengths (IMS) and progressive isoinertial lifting evaluation (PILE) test.

Results

The VAS and RMDQ scores in WBVEG and CSEG statistically significantly decreased (p<0.05). The difference between the pre-treatment and at three-month VAS scores during intense activity were significantly different in both WBVEG and CSEG than the CG (p<0.05). The IMS values, except for the isokinetic flexion total work (IKFTW), increased significantly in all three groups (p<0.05). The IKFTW values increased significantly in the WBVEG and CSEG (p<0.05). A statistically significant increase in the functional work performance with PILE was observed in all three groups (p<0.05). The differences between the pre-treatment and three-month PILE test (ground to back and back to shoulder) were significantly different in both WBVEG and CSEG than the CG (p<0.05).

Conclusion

In the treatment of chronic NLBP, WBVE and CSE appear to be effective in pain and functionality. Although there was a significant improvement in muscle strength and functional work performance in all three groups, greater improvements were observed in the WBVEG and CSEG than the CG.

A Comprehensive Review of Cluneal Neuralgia as a Cause of Lower Back Pain

Lower back pain (LBP) is one of the most common presenting complaints in clinical adult medical patients. While most often diagnosed as "nonspecific mechanical" in etiology, several lesser known, rarer causes of LBP exist, some of which can even cause neuropathic pain. One of these infrequent causes, cluneal neuralgia (CN), is associated most often with damage or entrapment of the cluneal nerves, particularly the superior cluneal nerve (SCN) and/or the middle cluneal nerve (MCN). These nerves supply sensation to the posterior lumbar and buttock area. However, the LBP caused by CN is often difficult to recognize because it can mimic radiculopathy or sacroiliac joint (SIJ) pain or lead to symptoms in the legs. This makes CN significantly important for clinicians and surgeons to include in their differential. A thorough history proves beneficial in the diagnostic workup, as many risk factors for CN have been reported in the literature. If a CN diagnosis is made, several effective conservative measures can alleviate patients' pain, such as nerve blocks, peripheral nerve stimulation, or high frequency thermal coagulation. Additionally, surgical treatments, such as CN release or endoscopic decompression, have resulted in fantastic patient outcomes. The purpose of the present investigation is to investigate the existing literature about CN as a cause for LBP, consider its epidemiology, discuss its pathophysiology and risk factors, elucidate its clinical presentation and diagnosis, and examine the various treatment modalities that have been reported across the world.

The ESCAPE trial for older people with chronic low back pain: Protocol of a randomized controlled trial

Background

Low-back pain is one of the most common health conditions worldwide. It is defined as pain below the costal margin and above the inferior gluteal folds. Current guidelines recommend management of chronic health (e.g., low back pain) conditions in older people at primary health care settings using active strategies (e.g., exercise). In non-specific low back pain, high quality evidence supports active strategies for general population. However, the management of non-specific low back pain in the older people has been overlooked and evidence is limited to a small number of low powered randomized controlled trials with high risk of bias.

Methods

This is a prospectively registered, open, two-arm randomised controlled trial comparing the group-based exercise and waiting list in pain intensity (11-item Pain Numerical Rating Scale) and disability (Roland Morris questionnaire) of older people (i.e., 60 years old or over) with chronic non-specific low back pain. One hundred and twenty patients will be recruited from Diamantina, Brazil. Follow-ups will be conducted in post-treatment (8 week) and 6- and 12-months post-randomisation.

Discussion

Our hypothesis is that group-based exercise will be better than waiting list in reducing pain intensity and disability in older people with chronic non-specific low back pain.

Impact

The practice of individualized exercise has been studied for the management of chronic non-specific low back pain in older people. However, the group exercise, even showing high quality evidence for the improvement of several important outcomes in this population, has been ignored until now. Thus, the results of this study have the potential to indicate a viable and accessible strategy for managing chronic non-specific low back pain in the older people.

Trial registration

The study was prospectively registered at www.ensaiosclinicos.gov.br (RBR-9j5pqs). Date-11/18/2020.

Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis

BACKGROUND

Low back and neck pain are the most common musculoskeletal disorders worldwide, and imply suffering and substantial societal costs, hence effective interventions are crucial. The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working age persons with nonspecific back and/or neck pain.

METHODS

The two interventions were: a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage and stretching, performed by a naprapath (index group), respectively information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, at 2 occasions within 3 weeks (control group). A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health related QoL was calculated, and sensitivity analyses were performed.

RESULTS

The difference in QoL gains was 0.007 (95% CI - 0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068-1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person was estimated at - 437 EUR (95% CI - 1302 to 371) and for the pain outcome the difference was - 635 EUR (95% CI - 1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results.

CONCLUSIONS

Our results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted. Trial registration Current Controlled Trials ISRCTN56954776. Retrospectively registered 12 September 2006, http://www.isrctn.com/ISRCTN56954776 .

Profile of individuals with low back pain and factors defining chronicity of pain: a population-based study in Ethiopia

Purpose

Low back pain (LBP) is the most prevalent public health problem globally, second only to headaches in the ranking of painful disorders that affect human beings. However, evidence about the profile of LBP patients is lacking in low-income countries for appropriate management approaches. This study examined the profile of individuals with LBP and factors defining chronicity of pain in Ethiopia.

Methods

A population-based cross-sectional study design was used to collect data from 1812 adults (≥ 18 years) with LBP at present. Data were collected by interviewing the study participants using an instrument developed and validated in the same study population. The instrument includes socio-demographic information, health behaviours/lifestyle habits, beliefs about pain, and pain and general health-related characteristics of the participants. Data analysis was performed using R version 3.5.1. Both unconditional and conditional logistic regression models were fitted and Odds Ratio (OR) with 95% confidence intervals (95% CIs) were computed to identify factors significantly associated with chronicity of pain at p ≤ 0.05 significance level.

Results

Negative beliefs about pain, a varying degree of pain interference with daily and social activities, complaining of pain in other anatomical sites other than the low back region, general health status rated as not excellent, depressive symptomology, and sleeping problems/insomnia were common within the profile of individuals with LBP. Age, educational level, residential setting, beliefs about pain, and depressive symptomology were found to have a statistically significant association with chronicity of pain.

Conclusions

This study provides an overview of the profile of individuals with LBP and factors defining chronicity of pain, assisting clinicians to design appropriate management strategies to improve patients' outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03148-5.

Evaluation of intervertebral disc degeneration using T2 signal ratio on magnetic resonance imaging

PURPOSE

Intervertebral disc degeneration is assessed clinically by magnetic resonance imaging (MRI). Although some quantitative evaluation methods for MRI under special imaging conditions have been reported, they are widely and generally difficult to use. The aim of this study is to determine if intervertebral disc degeneration can be assessed using the ratio of MRI T2 values of the disc to the spinal cord T2 values.

METHODS

Signal ratio was calculated using the T2 signal intensity of the disc and the spinal cord on MRI under common conditions for a new assessment of disc degeneration. T2-weighted images of 100 patients undergoing MRI twice within a year under different imaging conditions, 1.5 T or less and 3.0 T, were used for the assessment. The T2 signal intensity was measured at the center of the discs at L2-3, L3-4, L4-5, L5-S1 and the spinal cord at T12 level. Signal ratio was calculated using these T2 signal intensity values. The ratio of the difference between the first and second values to the mean of the first and second values was calculated to confirm the equivalence of MRI assessments of disc degeneration in the same patient under different imaging conditions.

RESULTS

The equivalence of values between the first MRI and the second MRI in the signal ratio was significantly higher than that in the T2 signal intensity. In addition, the signal ratio was negatively correlated with age and were significantly associated with Pfirrmann grade.

CONCLUSIONS

By using the signal ratio, disc degeneration can be evaluated by MRI even under different imaging conditions.

Scoliosis and skeletal muscle mass are strongly associated with low back pain-related disability in humans: An evolutionary anthropology point of view

OBJECTIVES

To clarify the potential risk factors and etiology of low back pain (LBP)-related disability, including structural changes of the spine (spinal scoliosis) and body composition components in a population with a high prevalence of LBP.

METHODS

In this cross-sectional study, two self-reported validated questionnaires were used to collect back pain and disability data in an ethnically homogeneous family-based population sample (N = 1078). The scoliosis angle of trunk rotation was measured by a scoliometer on three spinal levels while the patient was bent forward. Body composition parameters, including relative to weight (WT), fat, relative skeletal muscle mass (SMM/WT), and total body water were determined by bioelectrical impedance analysis. Statistical analysis was conducted, accounting for the familial composition of the sample.

RESULTS

The mixed multiple regression analyses with several LBP-related phenotypes as dependent variables consistently showed significant independent associations with scoliosis and SMM/WT, irrespective of other covariates. The odds ratios (OR)/95% CI for scoliosis ranged between 1.40 (1.19-1.64) and 1.51 (1.27-1.80), and from 0.61(0.51-0.72), to 0.71(0.58-0.87) for SMM/WT, depending on the LBP phenotype. The genetic components of the respective correlations between the LBP-phenotypes and scoliosis or SMM/WT were negligible.

CONCLUSIONS

The associations between LBP-related conditions and postured scoliosis and SMM/WT were consistent and significant and therefore may serve as markers in predicting the development of LBP-related disability. We interpret the origin of these correlations as the evolutionary event due to the imperfect spine anatomy adaptation to a vertical posture resulting from a quick transition to bipedalism from a quadrupedal ancestor.

Acupuncture for Pain and Function in Patients with Nonspecific Low Back Pain: Study Protocol for an Up-to-Date Systematic Review and Meta-Analysis

Aim

Design

Methods

Results

Effectiveness and Safety of Inelastic Versus Elastic Lumbosacral Orthoses on Low Back Pain Prevention in Healthy Nurses: A Randomized Controlled Trial

STUDY DESIGN

A randomized controlled trial.

OBJECTIVE

To evaluate the effects of inelastic and elastic lumbosacral orthoses (LSOs) on the prevention of low back pain (LBP) in healthy nurses.

SUMMARY OF BACKGROUND DATA

Over 80% of people experience LBP during their lifetime. LSOs, as a device used to maintain lumbar stability, were widely used in LBP management. The effects of inelastic LSOs (iLSOs) and elastic LSOs (eLSOs) on the prevention of LBP are controversial.

METHODS

A randomized clinical trial recruiting healthy nurses was conducted from November 2011 to June 2013 at a tertiary hospital in China. A total of 300 eligible participants aged 20 to 25 years were randomly assigned to iLSO, eLSO, or control groups. The intervention period was 6 months, and follow-ups were continued for an additional 6 months. Participants in both iLSO and eLSO groups were required to wear LSOs daily. Outcomes included the incidence of LBP, changes in trunk muscle endurance, and spinal range of motion assessed at baseline, 6months, and 12 months from the starting date. The incidence of LBP among groups was analyzed by ANOVA. Wilcoxon rank-sum test, Kruskal-Wallis H test, etc. were used for secondary outcomes comparison across groups.

RESULTS

Two hundred seventy-eight out of 300 participants (92.7%) completed the trial. No statistically significant differences were observed in LBP incidence among the three groups. No difference was observed in abdominal/back muscle endurance among groups at 6 months. In secondary outcome analysis regarding spinal range of motion, flexion and extension improved in iLSO groups at 12 months compared with that at baseline (flexion, P  = 0.01; extension, P  = 0.01), whereas only extension motion improved at 12 months in the eLSO group (P  = 0.00).

CONCLUSIONS

Six-month wearing of LSO showed neither a significant difference in preventing LBP nor causing adverse effects to participants.Level of Evidence: 1.

Proprioceptive manipulations in orthograde posture modulate postural control in low back pain patients: a pilot study

As we stand upright, perceptual afferences are crucial to successfully help generating postural motor commands. Non-Specific Low Back Pain patients frequently demonstrate a lack of proprioceptive acuity, often translating into postural control deficiencies. For the first time, to our knowledge, we studied the postural effects of proprioceptive manipulations in orthograde posture on Non-Specific Low Back Pain patients. Using static posturography recordings, we computed sway speed, speed variance, and the main direction of sway. We also addressed the patient’s subjective feedbacks after being manipulated. Five minutes after the proprioceptive manipulations, our results revealed decreased speed and speed variance outcomes, but the main direction of sway was not modulated. Furthermore, after the proprioceptive manipulations, the patients also self-reported improved clinical outcomes. These findings provide new knowledge opening new fields of research as well as potential treatment strategies in Low Back Pain patients.

Nonoperative treatment for pain sensitization in patients with low back pain: protocol for a systematic review

BACKGROUND

Low back pain is a disability that occurs worldwide. It is a heterogeneous disorder that affects patients with dominant nociceptive, neuropathic, and central sensitization pain. An important pathophysiology of low back pain involves pain sensitization. Various nonoperative interventions are available for treatment, but there is inconclusive evidence on the effectiveness of these interventions for pain sensitization, leading to arbitrary nonoperative treatments for low back pain.

METHODS

We will conduct a systematic review of RCTs evaluating the effectiveness and safety of nonoperative treatment for pain sensitization in patients with low back pain. The primary outcomes will be static quantitative sensory testing, dynamic quantitative sensory testing, and pain algometry. The secondary outcome will be adverse events. We will search the PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Library databases. Two independent authors will screen the titles and abstracts, review full texts, extract data, assess the risk of bias, and evaluate the quality of evidence. We will qualitatively and quantitatively synthesize the results using a random effects model for meta-analysis.

DISCUSSION

This systematic review aims to provide evidence regarding which treatment, if any, provides the greatest benefit for pain sensitization and safety among patients with low back pain. Evidence synthesized from this systematic review will inform clinical practice and further research. Since there is still a small amount of research, additional studies might need to be conducted in the future.

SYSTEMATIC REVIEW REGISTRATION

Submitted to PROSPERO on March 20, 2021, CRD42021244054.

Cross-cultural adaptation and validation of the simplified chinese version of the fremantle back awareness questionnaire in patients with low back Pain

PURPOSE

The Fremantle back awareness questionnaire (FreBAQ) was recently developed as simple and quick tool to assess back-specific body perception in Low back pain (LBP) patients. The aim of the present study was to translate and cross-culturally adapt the Fremantle back awareness questionnaire (FreBAQ) into a Simplified Chinese version (FreBAQ-C), and evaluate the reliability and validity of the FreBAQ-C in patients with non-specific Chronic Low back pain (CLBP).

METHODS

The FreBAQ was translated into Chinese according to established methods. Internal consistency was assessed according to Cronbach's alpha. Test-retest reliability was estimated by Intraclass correlation coefficient (ICC). Construct validity was evaluated by correlations between the FreBAQ-C and Visual analogue scale (VAS), Roland-Morris disability questionnaire (RDQ), Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK) as well as Hospital anxiety and depression scale (HADS).

RESULTS

A total of 105 participants (38 males and 67 females) were included in this study with the mean age of 54.1 ± 15.6 years, mean duration of LBP of 6.8 ± 4.6 years. The FreBAQ-C total scores were well distributed, with no floor or ceiling effects. Internal consistency was excellent (Cronbach's alpha = 0.833). ICC of test-retest reliability was good (0.897, 95% confidence interval: 0.852-0.929). The limits of agreement (LOA) ranged from - 5.8 to 6.3. The Standard error of measurement (SEM) and Minimum detectable change (MDC) were 2.16 and 5.99. Construct validity was confirmed by significant correlation of The FreBAQ-C and VAS during motion (r = 0.274, p = 0.005) and rest (r = 0.243, p = 0.012), RDQ (r = 0.377, p < 0.001), PCS (r = 0.439, p < 0.001), and TSK(r = 0.311, p = 0.001).

CONCLUSIONS

The FreBAQ-C was demonstrated to have acceptable reliability and validity for patients with non-specific CLBP in Chinese mainland. It will allow evaluating body preception of the back in the Chinese population with CLBP.

Effectiveness of Acupuncture for Nonspecific Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Objective

This systematic review and meta-analysis assess the effectiveness of acupuncture as an adjunct to standard therapy in the management of nonspecific chronic low back pain (NScLBP), compared with standard therapy alone.

Methods

A systematic literature search of full-text articles of randomized controlled trials in the date range of 2000-2020, utilizing PubMed and EBSCO databases, was performed to evaluate the efficacy of acupuncture treatment for nonspecific chronic lower back pain. The outcomes of interest were pain intensity and disability. The methodological quality of each study was evaluated using Cochrane risk-of-bias criteria. The studies were combined using meta-analysis when statistical pooling of data was possible.

Results

This systematic review included 5 studies of which 4 were included in the meta-analysis. Acupuncture as an adjunct to standard therapy had clinically meaningful reduction in self-reported pain at post-treatment (mean difference = -1.04 [95% confidence interval (CI), -1.59 to -0.49], P < 0.001, I 2 = 46.1%) and at intermediate term (mean difference = -0.82 [95% CI, -1.13 to -0.50], P < 0.001, I 2 = 0%), compared with standard care. Levels of disability showed similar clinically meaningful reduction at post-treatment and intermediate term.

Conclusion

Both the systematic review and meta-analysis demonstrate that acupuncture as an adjunct to standard therapy is a safe and effective method in reducing pain and disability among adults with NScLBP.

Decreasing prevalence of chronic back pain in Catalonia. Analysis of the Catalan Health Survey

OBJECTIVES

Chronic back pain is one of the main health problems reported by the adult population and its prevalence is influenced by different sociodemographic, work and lifestyle-related factors. The aim of this study was to describe the trend in the lifetime prevalence of chronic back pain in the adult Catalan population between 2011 and 2018 and its associated factors.

STUDY DESIGN

Cross-sectional study. Secondary analysis of a health survey.

METHODS

Trend in lifetime prevalence of chronic back pain by age and sex groups was estimated from the Catalan Health Survey. Association of chronic back pain with sex, age, health status, lifestyle factors, comorbidities, socio-economic and work-related variables was analysed.

RESULTS

A total of 31,823 people were interviewed between 2011 and 2018. The prevalence of chronic back pain decreased from 29.7% to 24.2% between 2011-2014 and 2015-2018 in the total population with higher prevalence and a greater difference in women (35%-28.50%) than in men (24.2%-19.7%). Factors associated with higher prevalence of chronic back pain were female sex, older age, poor health status, smoking, alcohol consumption, insufficient physical activity, overweight or obesity, mental health problems, lower educational level or social class, dissatisfaction at workplace, poor social support and family financial problems.

CONCLUSIONS

The analysis shows a decreasing prevalence of chronic back pain from 2011 to 2018 in the adult population of Catalonia in all age groups and more significantly in women. An improvement of healthy lifestyle habits, social and occupational determinants, could have reduced the burden of chronic back pain in our community.

lncRNA LINC00284 promotes nucleus pulposus cell proliferation and ECM synthesis via regulation of the miR‑205‑3p/Wnt/β‑catenin axis

Intervertebral disc degeneration (IDD) is a leading cause of degenerative spinal disease. Long non-coding RNA (lncRNA) LINC00284 is overexpressed in multiple types of cancer and promotes cancer cell proliferation and inhibits apoptosis; however, its role in human IDD and nucleus pulposus (NP) remain unclear. In the present study, intervertebral disc (IVD) tissues were collected from IDD patients for detection of LINC00284 expression using reverse transcription-quantitative PCR, the binding effect between miR-205-3p and LINC00284 was validated by dual-luciferase reporter assay. miR-205-3p and small interfering RNA (siRNA) was used for LINC00240 knockdown to investigate the proliferation, apoptosis of cells in the NP cells measured by Cell Counting Kit (CCK)-8 assay and Annexin V-FITC/Propidium Iodide (PI) staining with flow cytometry receptivity. IDD animal models were constructed for in vivo study of the role LINC00284 in IDD improvement. The results showed that LINC00284 expression was upregulated in IDD tissue and IL-1β-induced NP cells. LINC00284 knockdown resulted in an increase in IL-1β-induced NP cell proliferation, a decrease in apoptosis and matrix metalloproteinase-3 expression and an increase in expression of extracellular matrix (ECM) markers aggrecan and collagen II. In vivo experiments and histomorphometric analysis confirmed the protective effect of LINC00284 knockdown in IDD. LINC00284 was also shown to be a target of microRNA (miR)-205-3p, and there was a negative correlation between LINC00284 and miR-205-3p levels in IDD tissue. Additionally, LINC00284 knockdown or miR-205-3p upregulation resulted in inhibition of Wnt/β-catenin signaling and subsequent degradation of the ECM. The present study demonstrated that LINC00284 activated the Wnt/β-catenin signaling via sponging miR-205-3p, resulting in inhibition of NP cell proliferation and ECM synthesis. These results suggested that targeting LINC00284 to rescue miR-205-3p expression may be a potential method for IDD management.

Patients with low back pain use stiffening strategy to compensate for movement control during active prone hip rotation: A cross-sectional study

BACKGROUND

New motor adaptation to pain theory suggests that patients with low back pain (LBP) use the lumbopelvic stiffening strategy by redistribution of within and between muscle activities to protect painful structure. This could result in an altered postural control of the lumbopelvic region during active prone hip rotation (PHR).

OBJECTIVE

To investigate coordination and timing of lumbopelvic and hip movements, and smoothness of the lumbopelvic control during PHR between participants with and without LBP.

METHODS

Eight participants with LBP and eight participants without LBP were recruited. The electromagnetic tracking system was used to record kinematic data during PHR. Cross-correlation between hip rotation and lumbopelvic movement in the transverse plane was calculated. Correlation at zero time-lag, time-lag, correlation at time-lag, and maximal lumbopelvic motion were derived. Frequency of movement disruption was identified. An independent t-test was used in conjunction with the effect size and 95% minimal detectable difference (MDD95) to determine the difference in kinematic parameters.

RESULTS

Participants with LBP demonstrated a significant delay (exceeding MDD95) in lumbopelvic motion while nonsignificant frequency of disrupted motion on the painful side PHR demonstrated a trend with a large effect size that exceeded MDD95. There were trends with moderate to large effect sizes and differences exceeding MDD95 in delay of lumbopelvic motion with greater movement disruption on the nonpainful side in participants with LBP.

CONCLUSION

Participants with LBP used a lumbopelvic stiffening strategy for postural control to protect painful structures; however, the stiffening might complicate efforts to smoothly control lumbopelvic movement.

Prevalence of Sarcopenia in Pain Patients and Correlation Between the 2 Conditions: A Systematic Review and Meta-analysis

OBJECTIVES

Sarcopenia is a generalized and progressive skeletal muscle disorder and has been proven to be associated with many diseases; however, the correlation between sarcopenia and pain has not yet been systematically clarified. This review aimed to investigate the prevalence of sarcopenia in patients with pain and to ascertain whether pain is independently associated with sarcopenia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

A systematic literature search was performed from the Cochrane Central Register of Controlled Trials, Embase, MEDLINE and Epub Ahead of Print, In-Process, In-Data-Review, and Other Non-Indexed Citations, Daily and Versions for observational studies from inception until February 2021, and our search was updated on December 31, 2021.

METHODS

Sarcopenia prevalence was calculated according to the corresponding number of patients with sarcopenia and pain. We performed meta-analyses with random effects models to calculate the pooled prevalence of sarcopenia in pain and its correlations. Subgroup analyses were also performed based on pain classification, pain location, and diagnostic criteria for sarcopenia. Heterogeneity between the studies was described using the I² statistic.

RESULTS

Fourteen observational studies (13,953 participants, 44% women, and mean age from 40.1 to 76.6 years) were included. Study quality was rated moderate to high. The overall sarcopenia prevalence in patients with pain was 0.11 (95% CI 0.07-0.15, P < .001; I² = 92.3%). People with pain were independently associated with a higher risk of sarcopenia than those without pain (odds ratio [OR] 1.35; 95% CI 1.17-1.56; P = .025; I² = 51.1%). Subgroup analyses showed that the cumulative prevalence and effect measures of sarcopenia were increased when individuals suffered secondary musculoskeletal pain (Prevalence = 12%; OR 1.45; 95% CI 1.19-1.78) and low back pain (Prevalence = 21%; OR 1.95; 95% CI 1.22-3.12).

CONCLUSIONS AND IMPLICATIONS

The prevalence of sarcopenia in patients with pain is relatively high, and pain is significantly associated with sarcopenia in older adults. Attention is needed to screen sarcopenia among patients with pain and optimize its early detection and management in clinical practice.

Translation and Adaptation of the French Version of the Risk Stratification Index, a Tool for Stratified Care in Chronic Low Back Pain: A Pilot Study

Background and Objectives: Low back pain is a worldwide health problem. An early diagnosis is required to develop personalized treatment strategies. The Risk Stratification Index (RSI) was developed to serve the purpose. The aim of this pilot study is to cross-culturally translate the RSI to a French version (RSI-F) and evaluate the test-retest reliability of RSI-F using a French active population. Materials and Methods: The RSI was translated from German to French (RSI-F) based on the guidelines of cross-cultural adaptation of self-report measures. A total of 42 French recreational athletes (age 18−63 years) with non-specific low back pain were recruited and filled in the RSI-F twice. The test-retest reliability was examined using intraclass correlation coefficient (ICC1,2) and Pearson correlation coefficient. Results: Finally, 33 questionnaires were analyzed (14 males and 19 females, age 31 ± 10 years, 9.5 ± 3.2 h/week of training). The test-retest of RSI-F CPI and DISS were excellent (CPI: ICC1,2 = 0.989, p < 0.001; r = 0.989, p < 0.001; DISS: ICC1,2 = 0.991, p < 0.001; r = 0.991, p < 0.001), as well as Korff pain intensity (ICC1,2 = 0.995, p < 0.001; r = 0.995, p < 0.001) and disability (ICC1,2 = 0.998, p < 0.001; r = 0.998, p < 0.001). Conclusion: The RSI-F is linguistically accurate and reliable for use by a French-speaking active population with non-specific low back pain. The RSI-F is considered a tool to examine the evolution of psychosocial factors and therefore the risk of chronicity and the prognostic of pain. Further evaluations, such as internal, external validity, and responsiveness should be evaluated in a larger population.

Associations of walking and resistance training with chronic low back pain in older adults: A cross-sectional analysis of Korean National Health and Nutrition Examination Survey data

ABSTRACT

Physical activities, such as resistance training and walking, are known to be effective against chronic low back pain (CLBP). However, few studies have examined the associations of walking and resistance training with CLBP in the general older population. Therefore, this study analyzed these relationships in the older Korean population (aged ≥65 years), with the goal of determining which exercise is better for CLBP.This cross-sectional study analyzed Korean National Health and Nutrition Examination Survey data for the period 2012 to 2015. The Korean National Health and Nutrition Examination Survey, which provides representative data for the Korean population, uses a clustered, multistage, random sampling method with stratification based on geographic area, age, and sex. Three multiple logistic regression models were generated in this study to determine the associations of walking and resistance training with CLBP.A total of 5233 participants were enrolled, 3641 (69.6%) of whom were free from CLBP; the remaining 1592 (30.4%) had CLBP. 78.4% and 64.8% of the non-CLBP and CLBP group patients, respectively, walked at least once a week. Also, 23.5% and 11.6% of the participants in the non-CLBP and CLBP groups, respectively, engaged in resistance training at least once a week. In the multiple logistic regression analysis, which was adjusted for all potential confounders, walking was significantly associated with a lower risk of CLBP (1-2d/wk: odds ratio [OR] = 0.65, P = .002; 3-4d/wk: OR = 0.69, P = .004; ≥5 d/wk: OR = 0.57, P < .001). However, resistance training showed no association with the risk of CLBP.In this cross-sectional study, walking was associated with a lower risk of CLBP. In particular, walking >5days per week had the maximum benefit in a lower risk of CLBP. Therefore, clinicians can consider recommending walking to patients with CLBP for optimal pain improvement.

Goal Attainment Scaling in Outpatient Physical Therapy for Chronic Low Back Pain: Protocol for a Mixed Methods Study

Background

Patient engagement in decisions regarding their health care may lead to improved outcomes and improved adherence to treatment plans. While there are several options for involving patients in their health care, goal setting is a readily accessible method for physical therapists to increase the involvement of patients in health care decisions. Physical therapy goals are often generated by health care providers based on subjective information or standardized, fixed-item, patient-reported outcome measures. However, these outcome measures may not fully reveal the activity and participation limitations of individual patients. Goal attainment scaling (GAS) is a patient-centered approach that allows patients to set meaningful goals. While GAS has been shown to be reliable, valid, and sensitive to change in various populations, there is limited evidence in the United States on utilizing GAS in physical therapy for patients with chronic low back pain (LBP).

Objective

The purpose of this paper is to describe the protocol for a study to (1) develop a way to apply GAS procedures for physical therapists treating patients with chronic LBP in the United States and (2) test the feasibility of applying GAS procedures for chronic LBP in an outpatient physical therapy setting.

Methods

This study used a mixed methods design with 2 phases: qualitative and quantitative. The qualitative phase of the study employed focus groups of patients with chronic LBP to identify an inventory of goals that were important and measurable. A series of prompts was developed from this inventory to assist physical therapists in collaboratively establishing goals with patients in a clinical setting. The quantitative phase of the study pilot-tested the inventory developed in the qualitative phase in patients with chronic LBP to determine feasibility, reliability, validity, and responsiveness. We also plan to compare how well GAS reveals change over time relative to traditional, fixed-item, patient-reported measures.

Results

Phase 1 data collection was completed in June 2020, while data collection for phase 2 was performed between March 2021 and December 2021. We anticipate that this study will demonstrate that GAS can be implemented successfully by outpatient physical therapists, and that it will demonstrate clinically important changes in patients with chronic LBP.

Conclusions

GAS represents an opportunity for patient-centered care in the physical therapy management of chronic LBP. While GAS is not new, it has never been studied in real-world physical therapy for chronic LBP in a clinical setting. Due to unique time and productivity constraints, for GAS to be successfully implemented in this environment, we must demonstrate that clinicians can be trained efficiently and reliably, that GAS can be implemented in a clinical setting in under 15 minutes, and that GAS is able to detect clinically meaningful changes in patient outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32457