Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults

Development of a vocational rehabilitation intervention to support return-to-work and well-being following major trauma: a person-based approach

OBJECTIVES

Major trauma centres (MTCs) save lives but rehabilitation to support return-to-work (RTW) is lacking. This paper describes development of a vocational rehabilitation intervention (the ROWTATE intervention) to support RTW following traumatic injury.

DESIGN

Sequential and iterative person-based approach in four stages-Stage 1: review of evidence about the efficacy and mechanisms of RTW interventions; Stage 2: interviews (n=38) and focus groups (n=25) with trauma survivors and service providers in five UK MTCs to identify the issues, and challenges faced postinjury; Stage 3: codesign workshops (n=43) with trauma stakeholders in MTCs to conceptually test and identify intervention delivery barriers/enablers; Stage 4: meetings (n=7) with intervention development working group (IDWG) to: (1) generate guiding principles, (2) identify key intervention features (process, components, mechanisms) to address unmet rehabilitation needs; (3) generate a logic model and programme theory to illustrate how the intervention works; and (4) develop a training package to support delivery.

RESULTS

Trauma survivors described unmet needs relating to early advice about RTW; psychological support; pain management; hidden disabilities (eg, fatigue); estimating recovery; and community, amputee and musculoskeletal rehabilitation. Mechanisms of effective interventions identified in the review included early intervention, colocation, employer engagement, case coordination and work accommodations. Intervention features identified by IDWG members (n=13) from stages 1 and 2 were use of stepped-care approaches by occupational therapists (OTs) and clinical psychologists (CPs), OT/CP formulation for complex cases, assessment of mental health problems, individually tailored rehabilitation including vocational goal setting, cross-sector coordination/communication, employer engagement, phased RTW, education/advice for family/employers, exploration of work alternatives, ongoing review of physical and mental health needs, work stability monitoring. Conceptual testing ratified the logic model. Geography and long waiting lists were identified as potential delivery barriers.

CONCLUSIONS

Real-world testing of the intervention is underway in a randomised controlled trial.

Assessing multidisciplinary follow-up pattern efficiency and cost in follow-up care for patients in cervical spondylosis surgery: a non-randomized controlled study

Background

The use of multidisciplinary treatment programs in out-of-hospital healthcare is a new area of research. Little is known about the benefits of this method in the management of discharged patients undergoing cervical spondylosis surgery.

Objective

This study aimed to explore the effect of a contracted-based, multidisciplinary follow-up plan in patients after cervical spondylosis surgery.

Methods

This non-blinded non-randomized controlled study was conducted with 88 patients (44 in the intervention group, 44 in the control group). The clinical outcomes, including Neck Disability Index (NDI), pain score (VAS), Self-Efficacy for Managing Chronic Disease 6-item Scale (SECD-6), and 12-Item Short-Form Health Survey (SF-12) score were assessed at the time of discharge, 24-72 h, 1 month, and 3 months post-discharge. The complications, patient satisfaction, and economic indicators were assessed at the final follow-up (3 months).

Results

Patients who received contracted follow-up showed greater improvement in neck dysfunction at 24-72 h, 1 month, and 3 months after discharge compared to those who received routine follow-up (p < 0.001). At 1 month after discharge, the intervention group exhibited better self-efficacy (p = 0.001) and quality of life (p < 0.001) than the control group, and these improvements lasted for 3 months. The intervention group reported lower pain scores at 24-72 h and 1 month (p = 0.008; p = 0.026) compared to the control group. The incidence of complications was significantly lower in the intervention group (11.4%) compared to the control group (40.9%). The total satisfaction score was significant difference between the two groups (p < 0.001). Additionally, the intervention group had lower direct medical costs (p < 0.001), direct non-medical costs (p = 0.035), and total costs (p = 0.04) compared to the control group. However, there was no statistically significant difference in indirect costs between the two groups (p = 0.59).

Conclusion

A multidisciplinary contract follow-up plan has significant advantages regarding neck disability, self-efficacy, quality of life, postoperative complications, patient satisfaction, and direct costs compared with routine follow-up.

The Web-Based Pain-at-Work Toolkit With Telephone Support for Employees With Chronic or Persistent Pain: Protocol for a Cluster Randomized Feasibility Trial

BACKGROUND

Chronic or persistent pain affects one's ability to work or be productive at work, generating high societal and economic burden. However, the provision of work-related advice and support for people with chronic pain is variable or lacking. The Pain-at-Work (PAW) Toolkit was cocreated with people who live with pain, health care professionals, and employers. It aims to increase knowledge about employee rights and how to access support for managing a painful chronic condition in the workplace and provides advice on lifestyle behaviors that facilitate the management of chronic pain.

OBJECTIVE

We aimed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing access to the PAW Toolkit and telephone support calls from an occupational therapist (PAW) with treatment as usual (ie, standard support from their employer). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, and safety of this digital workplace health intervention. We will assess the candidate primary and secondary outcomes' feasibility and test research processes for a definitive trial.

METHODS

This is an open-label, parallel 2-arm pragmatic feasibility cluster randomized controlled trial with exploratory health economics analysis and a nested qualitative interview study. We aim to recruit 120 participants from at least 8 workplace clusters (any type, >10 employees) in England. The recruitment of workplaces occurs via personal approach, and the recruitment of individual participants is web based. Eligible participants are vocationally active adults aged ≥18 years with internet access and self-reporting chronic pain interfering with their ability to undertake or enjoy productive work. A restricted 1:1 cluster-level randomization is used to allocate employment settings to PAW or treatment as usual; participants are unblinded to group allocation. Following site- and individual-level consent, participants complete a web-based baseline survey (time 0), including measures of work capacity, health and well-being, and health care resource use. Follow-up is performed at 3 months (time 1) and 6 months (time 2). Feasibility outcomes relate to recruitment; intervention fidelity (eg, delivery, reach, uptake, and engagement); retention; and follow-up. Qualitative evaluation (time 2) is mapped to the Capability, Opportunity, Motivation-Behavior model and will explore intervention acceptability to employees and employers, along with individual and contextual factors influencing the delivery and uptake of the intervention.

RESULTS

Ethics approval was obtained in March 2023. Trial recruitment began in June 2023.

CONCLUSIONS

The PAW Toolkit is the first evidence-based digital health intervention aimed at supporting the self-management of chronic or persistent pain at work. This study will inform the design of a definitive trial, including sample size estimation, approaches to cluster site identification, primary and secondary outcomes' selection, and the final health economic model. Findings will inform approaches for the future delivery of this digital health intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05838677; https://clinicaltrials.gov/study/NCT05838677.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51474.

Trends of Low Back Pain Research in Older and Working-Age Adults from 1993 to 2023: A Bibliometric Analysis

Although the number of publications focusing on low back pain in older adults (LBP-O) and working-age adults (LBP-W) has been growing for decades, comparative research trends in these two populations, which may help to guide future investigation, have not been rigorously explored. This analysis aimed to describe publication patterns and trends of research targeting LBP-O and LBP-W over the last three decades. Peer-reviewed LBP-O and LBP-W articles published between 1993 and 2023 were retrieved from the Web of Science, which provided the details of annual publication volume, and prominent journals/countries/institutions. The relationship between the annual publication volumes and years was analyzed by Spearman correlation analysis. The hot topics and emerging trends were analyzed by VOSviewer and CiteSpace, respectively. A total of 4217 LBP-O-related and 50,559 LBP-W-related documents were included. The annual publication volumes of LBP-O and LBP-W articles increased over the years (r=0.995 to 0.998, p<0.001). The United States had the highest number of prominent institutions publishing relevant articles. The most prolific journal for LBP-O (5.4%) and LBP-W-related (6.1%) papers is the journal "Spine". Cognitive behavioral therapy, intervertebral disc (IVD) degeneration, physiotherapy, physical activity, and walking were the recent hot topics and physical activity was an emerging trend in LBP-O, while surgery and IVD degeneration (also a hot topic) were emerging trends in LBP-W. This study highlights the paucity of LBP-O-related research in the past. The United States and the journal Spine stand out in LBP research. The research trend of physical activity in LBP-O is consistent with the recognized importance of physical activity for older adults in general, and for managing LBP-O in particular. Conversely, the emerging trends of surgery and intervertebral disc degeneration in LBP-W research highlight a focus on the biomedical model of LBP despite LBP being a biopsychosocial condition.

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.

Qualitative study exploring factors affecting the implementation of a vocational rehabilitation intervention in the UK major trauma pathway

OBJECTIVES

This study aimed to: (1) understand the context for delivering a trauma vocational rehabilitation (VR) intervention; (2) identify potential barriers and enablers to the implementation of a VR intervention post-trauma.

DESIGN

Qualitative study. Data were collected in person or via phone using different methods: 38 semistructured interviews, 11 informal 'walk-through care pathways' interviews, 5 focus groups (n=25), 5 codesign workshops (n=43). Data were thematically analysed using the framework approach, informed by the Consolidated Framework for Implementation Research.

SETTING

Stakeholders recruited across five UK major trauma networks.

PARTICIPANTS

A variety of stakeholders were recruited (n=117) including trauma survivors, rehabilitation physicians, therapists, psychologists, trauma coordinators and general practitioners. We recruited 32 service users (trauma survivors or carers) and 85 service providers.

RESULTS

There were several issues associated with implementing a trauma VR intervention including: culture within healthcare/employing organisations; extent to which healthcare systems were networked with other organisations; poor transition between different organisations; failure to recognise VR as a priority; external policies and funding. Some barriers were typical implementation issues (eg, funding, policies, openness to change). This study further highlighted the challenges associated with implementing a complex intervention like VR (eg, inadequate networking/communication, poor service provision, perceived VR priority). Our intervention was developed to overcome these barriers through adapting a therapist training package, and by providing early contact with patient/employer, a psychological component alongside occupational therapy, case coordination/central point of contact, and support crossing sector boundaries (eg, between health/employment/welfare).

CONCLUSIONS

Findings informed the implementation of our VR intervention within the complex trauma pathway. Although we understand how to embed it within this context, the success of its implementation needs to be measured as part of a process evaluation in a future trial.

Physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain: interventions and promising long-term outcomes

BACKGROUND

There is no consensus on best content, set-up, category of involved healthcare professionals or duration of rehabilitation-programs for patients with chronic musculoskeletal pain, and outcomes show varying results. Individual care regimes for sub-groups of patients have been proposed.

AIM

To describe the type of interventions used in a physiotherapist-led, rehabilitation-program for patients with chronic musculoskeletal pain, refractory to preceding treatments. A second aim was to report clinical outcomes at 1-year follow-up after the intervention period.

METHODS

All patients referred to physiotherapist within a specialist pain-unit due to being refractory to preceding treatments, and deemed fit to undergo physiotherapy-based, individualized rehabilitation during 2014-2018 were consecutively included and followed-up 1 year after ending the program. The inclusion was based on structured 'clinical reasoning' using the referral, examination and on patient-relevant outcome measures. The individual interventions, recorded according to a manual used when reading the patients' medical records, were described. Primary outcomes were clinical results of perceived pain, disability and overall health at start, discharge and 1 year after discharge.

RESULTS

In total, 274 patients (mean age 42 years, 71% women) were included, suffering from chronic, severe, musculoskeletal pain (VAS median 7/10, duration median 2.8 years) and moderate disability. The most frequent interventions were education, sensorimotor training, physical activity-advice and interventions for structures/functions (for example manual techniques, stretching) for a median of nine sessions during five months. Despite refractory to preceding treatments, 45% of the patients rated clinically important improvements on pain, 61% on disability and 50% on overall health at discharge and the figures were similar at 1-year follow-up.

CONCLUSIONS

A physiotherapist-led, one-to-one, rehabilitation-program of median nine sessions during five months, combining individualized education, sensorimotor training, physical activity-advice and interventions for structures/functions rendered clinically relevant improvements on pain, disability and overall health in half of the patients at 1-year follow-up. Since the cohort consisted of patients refractory to preceding treatments, we believe that these results warrant further studies to identify the subgroups of patients with chronic musculoskeletal pain that will improve from new, distinctive, resource-effective rehabilitation-programs involving individualized rehabilitation.

Results of a self-management program added to standard physical therapy in chronic neck pain

OBJECTIVE

To evaluate the effectiveness of a self-management treatment added to a physical therapy program compared to a physical therapy program in patients with chronic neck pain.

METHODS

Fifty-three patients with chronic neck pain were randomly allocated to a physical therapy intervention (control group) or an individualized self-management combined with physical therapy intervention (experimental group). Both interventions were developed over a four-week period. Outcome measures included were Disability, Fear-Avoidance Beliefs, Health-Related Quality of Life, Pain, and Anxiety and Depression. All outcomes were measured before and after the treatment and at three-month follow-up.

RESULTS

There were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).

CONCLUSIONS

An individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.

PRACTICAL IMPLICATIONS

This study indicates that physical therapy for patients with chronic neck pain preferably should include self-management education.

Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers’ expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings.

Vocational rehabilitation to enhance return to work after trauma (ROWTATE): protocol for a non-randomised single-arm mixed-methods feasibility study

Background

Traumatic injuries are common amongst working-age adults. Survivors often experience physical and psychological problems, reduced quality of life and difficulty returning to work. Vocational rehabilitation improves work outcomes for a range of conditions but evidence of effectiveness for those with traumatic injuries is lacking. This study assesses feasibility of delivering a vocational rehabilitation intervention to enhance return to work and improve quality of life and wellbeing in people with at least moderate trauma to inform design of a definitive randomised controlled trial (RCT).

Methods

Non-randomised, single-arm, multi-centre mixed-methods feasibility study with nested case studies and qualitative study. The case studies comprise interviews, observations of clinical contacts and review of clinical records. The qualitative study comprises interviews and/or focus groups. Participants will be recruited from two UK major trauma centres. Participants will comprise 40 patients aged 16–69 with an injury severity score of > 8 who will receive the intervention and complete questionnaires. Interviews will be conducted with 10 patients and their occupational therapists (OTs), clinical psychologists (CPs), employers and commissioners of rehabilitation services. Fidelity will be assessed in up to six patients by observations of OT and CP—patient contacts, review of patient records and intervention case report forms. OT and CP training will be evaluated using questionnaires and competence to deliver the intervention assessed using a team objective structured clinical examination and written task. Patients participating in and those declining participation in the study will be invited to take part in interviews/focus groups to explore barriers and facilitators to recruitment and retention. Outcomes include recruitment and retention rates, intervention fidelity, OT and CP competence to deliver the intervention, experiences of delivering or receiving the intervention and factors likely to influence definitive trial delivery.

Discussion

Effective vocational rehabilitation interventions to enhance return to work amongst trauma patients are urgently needed because return to work is often delayed, with detrimental effects on health, financial stability, healthcare resource use and wider society. This protocol describes a feasibility study delivering a complex intervention to enhance return to work in those with at least moderate trauma.

Trial registration

ISRCTN: 74668529. Prospectively registered on 23 January 20

A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK

Objective:

To identify where and how trauma survivors’ rehabilitation needs are met after trauma, to map rehabilitation across five UK major trauma networks, and to compare with recommended pathways.

Design:

Qualitative study (interviews, focus groups, workshops) using soft-systems methodology to map usual care across trauma networks and explore service gaps. Publicly available documents were consulted. CATWOE (Customers, Actors, Transformation, Worldview, Owners, Environment) was used as an analytic framework to explore the relationship between stakeholders in the pathway.

Setting:

Five major trauma networks across the UK.

Subjects:

106 key rehabilitation stakeholders (service providers, trauma survivors) were recruited to interviews (n = 46), focus groups (n = 4 groups, 17 participants) and workshops (n = 5 workshops, 43 participants).

Interventions:

None.

Results:

Mapping of rehabilitation pathways identified several issues: (1) lack of vocational/psychological support particularly for musculoskeletal injuries; (2) inconsistent service provision in areas located further from major trauma centres; (3) lack of communication between acute and community care; (4) long waiting lists (up to 12 months) for community rehabilitation; (5) most well-established pathways were neurologically focused.

Conclusions:

The trauma rehabilitation pathway is complex and varies across the UK with few, if any patients following the recommended pathway. Services have developed piecemeal to address specific issues, but rarely meet the needs of individuals with multiple impairments post-trauma, with a lack of vocational rehabilitation and psychological support for this population.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Development of a Japanese Version of a Collaborative Relationship Scale between Clients and Occupational Therapists

Objective:

The success of a client-centred practice depends on the relationship between the client and therapist and on their ability to make constructive decisions together, particularly in the field of occupational therapy. The aim of this study was to develop a Occupational Therapy Collaborative Relationship Scale (OTCRS) to measure the quality of such interaction.

Methods:

This work included constructing a draft questionnaire and testing its validity and reliability. A Rasch analysis was applied to determine its validity, and several tests were used to confirm its internal consistency.

Results:

After reviewing more than 130 scientific papers and books, we built explicit selection criteria for issues to be addressed in this instrument, and we developed 40 questions to be included. These were analysed using a standard content validation process and a Rasch analysis to examine confirmation validity. A nine-item scale was finalised for testing (OTCRS-9). This review process revealed the validity, high internal consistency, and item/person separation reliability of OTCRS-9.

Conclusion:

This study presents only the initial phase of scale development. As suggested by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN), the OTCRS-9 score should be tested further for validity and reliability and should also be conducted in subjects of other ethnicities to improve its generalizability.

Digital Treatment of Back Pain versus Standard of Care: The Cluster-Randomized Controlled Trial, Rise-uP

Purpose

Non-specific low back pain (NLBP) causes an enormous burden to patients and tremendous costs for health care systems worldwide. Frequently, treatments are not oriented to existing guidelines. In the future, digital elements may be promising tools to support guideline-oriented treatment in a broader range of patients. The cluster-randomized controlled “Rise-uP” trial aims to support a General Practitioner (GP)-centered back pain treatment (Registration No: DRKS00015048) and includes the following digital elements: 1) electronic case report form (eCRF), 2) a treatment algorithm for guideline-based clinical decision making of GPs, 3) teleconsultation between GPs and pain specialists for patients at risk for development of chronic back pain, and 4) a multidisciplinary mobile back pain app for all patients (Kaia App).

Methods

In the Rise-uP trial, 111 GPs throughout Bavaria (southern Germany) were randomized either to the Rise-uP intervention group (IG) or the control group (CG). Rise-uP patients were treated according to the guideline-oriented Rise-uP treatment algorithm. Standard of care was applied to the CG patients with consideration given to the “National guideline for the treatment of non-specific back pain”. Pain rating on the numeric rating scale was the primary outcome measure. Psychological measures (anxiety, depression, stress), functional ability, as well as physical and mental wellbeing, served as secondary outcomes. All values were assessed at the beginning of the treatment and at 3-month follow-ups.

Results

In total, 1245 patients (IG: 933; CG: 312) with NLBP were included in the study. The Rise-uP group showed a significantly stronger pain reduction compared to the control group after 3 months (IG: M=−33.3% vs CG: M=−14.3%). The Rise-uP group was also superior in secondary outcomes. Furthermore, high-risk patients who received a teleconsultation showed a larger decrease in pain intensity (−43.5%) than CG patients (−14.3%). ANCOVA analysis showed that the impact of teleconsultation was mediated by an increased training activity in the Kaia App.

Conclusion

Our results show the superiority of the innovative digital treatment algorithm realized in Rise-uP, even though the CG also received relevant active treatment by their GPs. This provides clear evidence that digital treatment may be a promising tool to improve the quality of treatment of non-specific back pain. In 2021, analyses of routine data from statutory health insurances will enable us to investigate the cost-effectiveness of digital treatment.

Role of diversity in assembling of rehabilitation teams in Central Europe

BACKGROUND

Multiprofessional teamwork in physical and rehabilitation medicine (PRM) allows achieving patient-centered goals in accordance with the assumptions of the bio-psycho-social model of functioning. Team composition and methods of collaboration depend of the specificity of goals to be achieved, as well local contextual factors. International comparative studies on rehabilitation teamwork are lacking, despite data on how teams differ between countries are crucial for the process of harmonization of PRM practice across Europe.

AIM

To compare models of collaboration within rehabilitation teams in Central Europe.

DESIGN

A cross-sectional explorative study.

SETTING

The data were collected in Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Slovakia between February and June 2018.

POPULATION

PRM physicians.

METHODS

An anonymous questionnaire inquiring of rehabilitation teamwork details was spread through national PRM societies, and other organizations associating PRM physicians. An ordered logit regression was applied to analyze the results.

RESULTS

Responses were obtained from 455 respondents. Significant differences between the studied countries in the composition of rehabilitation teams and frequencies of team meetings were detected. In the analyzed population of PRM physicians, we found positive associations between the chance of participation in team meetings and working in a hospital, the amount of time devoted to PRM practice, and older age. The chance for patients and caregivers to participate in rehabilitation team meetings was correlated with PRM physician's hospital practice, activity as a PRM teacher, older age and devoting more time to PRM practice. Country specificities of rehabilitation team content were analyzed with regards to local economic, legal, and historical backgrounds, and availability of human resources. Underrepresentation of key professionals (e.g. occupational therapists, orthotists/prosthetists), inadequate distribution of professionals in healthcare and as well as outdated educational systems in some countries may affect the efficacy of the comprehensive care in rehabilitation.

CONCLUSIONS

Central European countries differ in rehabilitation teamwork with regard to the contribution of professionals, meeting frequencies, and participation of patients and caregivers. Well-designed studies on teamwork models delineating ways to improve teamwork efficacy are in demand.

CLINICAL REHABILITATION IMPACT

Between-country diversity of rehabilitation team content should be considered while planning activities aimed at European harmonization of PRM practice.

Electronic measures of movement impairment, repositioning, and posture in people with and without neck pain-a systematic review

BACKGROUND

Neck pain is a major public health problem. Our objective was to describe differences in measures of movement and posture between people with and without neck pain.

METHODS

PubMed and Embase were searched before 15 February 2019 for studies comparing people with neck pain with controls using electronic measurements of neck movement and/or posture. Data were extracted on participants, device, test methods, active range of motion (RoM) and quality of motion, joint positioning sense, and posture. Study quality was assessed using the quality assessment of studies of diagnostic accuracy included in systematic reviews (QUADAS) and Guidelines for Reporting Reliability and Agreement Studies (GRRAS) guidelines.

RESULTS

Thirty-six studies were included: 24 studies included measurement of active RoM, 15 quality of motion, 12 joint positioning sense, and 5 cervical spine posture. Measurements and test methods were heterogeneous. The reporting of study populations and methods were poor, whereas devices and statistics were well described. All studies on RoM showed reduced active RoM in people with neck pain when compared with controls, 5 of 10 studies reported reduced movement speed for people with neck pain, and 5 of 9 studies reported significantly greater joint positioning error for people with neck pain compared with controls. Due to heterogeneous test parameters and methods, no conclusion regarding differences in conjunct motion, tracking a motion pattern, and measures of posture could be drawn.

CONCLUSIONS

People with neck pain appear to have reduced active RoM, movement speed, and head repositioning accuracy when compared with controls. However, quality of reviewed studies was low and better descriptions of participants and methods are required before firm conclusions can be drawn.

Immediate effect of pain neuroscience education for recent onset low back pain: an exploratory single arm trial

Study Design: A prospective, single-arm, pre-postintervention study.Objective: To determine the preliminary usefulness of providing pain neuroscience education (PNE) on improving pain and movement in patients presenting with non-chronic mechanical low back pain (LBP).Background: PNE has been shown to be an effective intervention for the treatment of chronic LBP but its usefulness in patients with non-chronic LBP has not been examined.Methods: A single group cohort pilot study was conducted. Eighty consecutive patients with LBP < 3 months completed a demographics questionnaire, leg and LBP rating (Numeric Pain Rating Scale - NPRS), disability (Oswestry Disability Index), fear-avoidance (Fear-Avoidance Beliefs Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), central sensitization (Central Sensitization Inventory), pain knowledge (Revised Neurophysiology of Pain Questionnaire), risk assessment (Keele STarT Back Screening Tool), active trunk flexion and straight leg raise (SLR). Patients received a 15-minute verbal, one-on-one PNE session, followed by repeat measurement of LBP and leg pain (NPRS), trunk flexion and SLR.Results: Immediately after intervention, LBP and leg pain improved significantly (p < 0.001), but the mean change did not exceed minimal clinically important difference (MCID) of 2.0. Active trunk flexion significantly improved (p < 0.001), with the mean improvement (4.7 cm) exceeding minimal detectible change (MDC). SLR improved significantly (p = 0.002), but mean change did not exceed MDC.Conclusions: PNE may be an interesting option in the treatment of patients with non-chronic mechanical LBP. The present pilot study provides the rationale for studying larger groups of patients in controlled studies over longer periods of time.

Non-pharmacological interventions for chronic pain in multiple sclerosis

BACKGROUND

Chronic pain is common and significantly impacts on the lives of persons with multiple sclerosis (pwMS). Various types of non-pharmacological interventions are widely used, both in hospital and ambulatory/mobility settings to improve pain control in pwMS, but the effectiveness and safety of many non-pharmacological modalities is still unknown.

OBJECTIVES

This review aimed to investigate the effectiveness and safety of non-pharmacological therapies for the management of chronic pain in pwMS. Specific questions to be addressed by this review include the following.Are non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) effective in reducing chronic pain in pwMS?What type of non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) are effective (least and most effective) and in what setting, in reducing chronic pain in pwMS?

SEARCH METHODS

A literature search was performed using the specialised register of the Cochrane MS and Rare Diseases of the Central Nervous System Review Group, using the Cochrane MS Group Trials Register which contains CENTRAL, MEDLINE, Embase, CINAHL, LILACUS, Clinical trials.gov and the World Health Organization International Clinical Trials Registry Platform on 10 December 2017. Handsearching of relevant journals and screening of reference lists of relevant studies was carried out.

SELECTION CRITERIA

All published randomised controlled trials (RCTs)and cross-over studies that compared non-pharmacological therapies with a control intervention for managing chronic pain in pwMS were included. Clinical controlled trials (CCTs) were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All three review authors independently selected studies, extracted data and assessed the methodological quality of the studies using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool for best-evidence synthesis. Pooling data for meta-analysis was not possible due to methodological, clinical and statistically heterogeneity of the included studies.

MAIN RESULTS

Overall, 10 RCTs with 565 participants which investigated different non-pharmacological interventions for the management of chronic pain in MS fulfilled the review inclusion criteria. The non-pharmacological interventions evaluated included: transcutaneous electrical nerve stimulation (TENS), psychotherapy (telephone self-management, hypnosis and electroencephalogram (EEG) biofeedback), transcranial random noise stimulation (tRNS), transcranial direct stimulation (tDCS), hydrotherapy (Ai Chi) and reflexology.There is very low-level evidence for the use of non-pharmacological interventions for chronic pain such as TENS, Ai Chi, tDCS, tRNS, telephone-delivered self-management program, EEG biofeedback and reflexology in pain intensity in pwMS. Although there were improved changes in pain scores and secondary outcomes (such as fatigue, psychological symptoms, spasm in some interventions), these were limited by methodological biases within the studies.

AUTHORS' CONCLUSIONS

Despite the use of a wide range of non-pharmacological interventions for the treatment of chronic pain in pwMS, the evidence for these interventions is still limited or insufficient, or both. More studies with robust methodology and greater numbers of participants are needed to justify the effect of these interventions for the management of chronic pain in pwMS.

Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study

The profession of the health-care providers (HCPs) influences their recommendations to the patients. Conversely, interdisciplinarity seeks to challenge such differences, so that the patient receives one single and consistent therapeutic message. Some studies also suggest associations between HCPs life habits and recommendations. Our hypotheses were (1) that despite interdisciplinary work, the profession remains a predictor of recommendations and (2) that HCPs who are more physically active recommend more activity. Three clinical vignettes were presented to a group of experts of low back pain (LBP) (guidelines), and 20 physicians, 22 physiotherapists, and 23 nurses to assess how they evaluate the symptoms and pathologies of LBP patients and how much work and physical activity they recommend. Physical activity was assessed with accelerometers and questionnaires. Some interprofessional differences remained present within an interdisciplinary team. The nurses were more restrictive and further away from the guidelines. The physicians were the most in line with them. The physiotherapists recommend as much physical activity, but less work activity than the physicians. The level of physical activity of the HCPs is not associated with their recommendations. To ensure a clear and unique message, educational actions may be undertaken to promote the biopsychosocial model and clarify the guidelines.

Return to Work in Employees on Sick Leave due to Neck or Shoulder Pain: A Randomized Clinical Trial Comparing Multidisciplinary and Brief Intervention with One-Year Register-Based Follow-Up

Purpose The aim of this study was to evaluate the effect of a multidisciplinary intervention (MDI) compared to a brief intervention (BI) with respect to return to work (RTW), pain and disability in workers on sick leave because of neck or shoulder pain. Methods 168 study participants with sickness absence for 4-16 weeks due to neck or shoulder pain were enrolled in a hospital-based clinical study and randomized to either MDI or BI. The primary outcome was RTW obtained by a national registry on public transfer payments. Secondary outcomes were self-reported pain and disability levels. One-year follow-up RTW rates were estimated by Cox proportional hazard regression adjusted for gender, age, sick leave prior to inclusion, part-time sick leave and clinical diagnosis. Secondary outcomes were analysed using logistic and linear regression analysis for pain and disability, respectively. Results In the MDI group, 50 participants (59%) experienced four or more continuous weeks of RTW while 48 (58%) returned to work in the BI group during the 1 year of follow-up. Results showed a statistically non significant tendency towards a lower rate of RTW in the MDI group than in the BI group (adjusted HR = 0.84, 95% CI 0.54, 1.31). There were no statistically significant differences in secondary outcomes between the MDI and BI groups. Conclusion The brief and the multidisciplinary interventions performed equally with respect to both primary and secondary outcomes. The added focus on RTW in the multidisciplinary group did not improve RTW rates in this group.

Towards an integrated clinical framework for patient with shoulder pain

Background

Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment.

Objectives

The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP.

Conclusion

The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE

This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out-of-pocket costs under proposed therapy caps.

METHOD

This retrospective, population-based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out-of-pocket costs.

RESULTS

Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12-14 visits.

DISCUSSIO

. Wide variation exists in potential patient out-of-pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.

Effectiveness of three interventions for secondary prevention of low back pain in the occupational health setting - a randomised controlled trial with a natural course control

BACKGROUND

We assessed the effectiveness of three interventions that were aimed to reduce non-acute low back pain (LBP) related symptoms in the occupational health setting.

METHODS

Based on a survey (n = 2480; response rate 71%) on LBP, we selected a cohort of 193 employees who reported moderate LBP (Visual Analogue Scale VAS > 34 mm) and fulfilled at least one of the following criteria during the past 12 months: sciatica, recurrence of LBP ≥ 2 times, LBP ≥ 2 weeks, or previous sickness absence. A random sample was extracted from the cohort as a control group (Control, n = 50), representing the natural course of LBP. The remaining 143 employees were invited to participate in a randomised controlled trial (RCT) of three 1:1:1 allocated parallel intervention arms: multidisciplinary rehabilitation (Rehab, n = 43); progressive exercises (Physio, n = 43) and self-care advice (Advice, n = 40). Seventeen employees declined participation in the intervention. The primary outcome measures were physical impairment (PHI), LBP intensity (Visual Analogue Scale), health related quality of life (QoL), and accumulated sickness absence days. We imputed missing values with multiple imputation procedure. We assessed all comparisons between the intervention groups and the Control group by analysing questionnaire outcomes at 2 years with ANOVA and sickness absence at 4 years by using negative binomial model with a logarithmic link function.

RESULTS

Mean differences between the Rehab and Control groups were - 3 [95% CI -5 to - 1] for PHI, - 13 [- 24 to - 1] for pain intensity, and 0.06 [0.00 to 0.12] for QoL. Mean differences between the Physio and Control groups were - 3 [95% CI -5 to - 1] for PHI, - 13 [- 29 to 2] for pain intensity, and 0.07 [0.01 to 0.13] for QoL. The main effects sizes were from 0.4 to 0.6. The interventions were not effective in reducing sickness absence.

CONCLUSIONS

Rehab and Physio interventions improved health related quality of life, decreased low back pain and physical impairment in non-acute, moderate LBP, but we found no differences between the Advice and Control group results. No effectiveness on sickness absence was observed.

TRIAL REGISTRATION

Number NCT00908102 Clinicaltrials.gov.

Intensive spa and exercise therapy program for returning to work for low back pain patients: a randomized controlled trial

We aimed to determine whether a 5-day intensive inpatient spa and exercise therapy and educational program is more effective than usual care in improving the rate of returning to work at 1 year for patients with subacute and chronic low back pain (LBP) on sick leave for 4 to 24 weeks. We conducted a 12-month randomized controlled trial. LBP patients were assigned to 5-day spa (2 hr/day), exercise (30 min/day) and education (45 min/day) or to usual care. The primary outcome was the percentage of patients returning to work at 1 year after randomization. Secondary outcomes were pain, disability and health-related quality of life at 1 year and number of sick leave days from 6 to 12 months. The projected recruitment was not achieved. Only 88/700 (12.6%) patients planned were enrolled: 45 in the spa therapy group and 43 in the usual care group. At 1 year, returning to work was 56.3% versus 41.9% (OR 1.69 [95% CI 0.60-4.73], p = 0.32) respectively. There was no significant difference for any of the secondary outcomes. However, our study lacked power.

Multidisciplinary biopsychosocial rehabilitation for subacute low back pain

BACKGROUND

Low back pain (LBP) is associated with enormous personal and societal burdens, especially when it reaches the chronic stage of the disorder (pain for a duration of more than three months). Indeed, individuals who reach the chronic stage tend to show a more persistent course, and they account for the majority of social and economic costs. As a result, there is increasing emphasis on the importance of intervening at the early stages of LBP.According to the biopsychosocial model, LBP is a condition best understood with reference to an interaction of physical, psychological, and social influences. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.This review is an update of a Cochrane Review on MBR for subacute LBP, which was published in 2003. It is part of a series of reviews on MBR for musculoskeletal pain published by the Cochrane Back and Neck Group and the Cochrane Musculoskeletal Group.

OBJECTIVES

To examine the effectiveness of MBR for subacute LBP (pain for a duration of six to 12 weeks) among adults, with a focus on pain, back-specific disability, and work status.

SEARCH METHODS

We searched for relevant trials in any language by a computer-aided search of CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and two trials registers. Our search is current to 13 July 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with subacute LBP. We included studies that investigated a MBR program compared to any type of control intervention. We defined MBR as an intervention that included a physical component (e.g. pharmacological, physical therapy) in combination with either a psychological, social, or occupational component (or any combination of these). We also required involvement of healthcare professionals from at least two different clinical backgrounds with appropriate training to deliver the component for which they were responsible.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. In particular, the data extraction and 'risk of bias' assessment were conducted by two people, independently. We used the Cochrane tool to assess risk of bias and the GRADE approach to assess the overall quality of the evidence for each outcome.

MAIN RESULTS

We included a total of nine RCTs (981 participants) in this review. Five studies were conducted in Europe and four in North America. Sample sizes ranged from 33 to 351. The mean age across trials ranged between 32.0 and 43.7 years.All included studies were judged as having high risk of performance bias and high risk of detection bias due to lack of blinding, and four of the nine studies suffered from at least one additional source of possible bias.In MBR compared to usual care for subacute LBP, individuals receiving MBR had less pain (four studies with 336 participants; SMD -0.46, 95% CI -0.70 to -0.21, moderate-quality of evidence due to risk of bias) and less disability (three studies with 240 participants; SMD -0.44, 95% CI -0.87 to -0.01, low-quality of evidence due to risk of bias and inconsistency), as well as increased likelihood of return-to-work (three studies with 170 participants; OR 3.19, 95% CI 1.46 to 6.98, very low-quality of evidence due to serious risk of bias and imprecision) and fewer sick leave days (two studies with 210 participants; SMD -0.38 95% CI -0.66 to -0.10, low-quality of evidence due to risk of bias and imprecision) at 12-month follow-up. The effect sizes for pain and disability were low in terms of clinical meaningfulness, whereas effects for work-related outcomes were in the moderate range.However, when comparing MBR to other treatments (i.e. brief intervention with features from a light mobilization program and a graded activity program, functional restoration, brief clinical intervention including education and advice on exercise, and psychological counselling), we found no differences between the groups in terms of pain (two studies with 336 participants; SMD -0.14, 95% CI -0.36 to 0.07, low-quality evidence due to imprecision and risk of bias), functional disability (two studies with 345 participants; SMD -0.03, 95% CI -0.24 to 0.18, low-quality evidence due to imprecision and risk of bias), and time away from work (two studies with 158 participants; SMD -0.25 95% CI -0.98 to 0.47, very low-quality evidence due to serious imprecision, inconsistency and risk of bias). Return-to-work was not reported in any of the studies.Although we looked for adverse events in both comparisons, none of the included studies reported this outcome.

AUTHORS' CONCLUSIONS

On average, people with subacute LBP who receive MBR will do better than if they receive usual care, but it is not clear whether they do better than people who receive some other type of treatment. However, the available research provides mainly low to very low-quality evidence, thus additional high-quality trials are needed before we can describe the value of MBP for clinical practice.

Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence

BACKGROUND & AIMS

Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.

METHODS

A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.

RESULTS

Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.

CONCLUSION

This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review

Objective:

To perform a systematic review of randomized controlled trials (RCTs) on the efficacy of therapeutic exercises for workers suffering from rotator cuff (RC) tendinopathy.

Methods:

A literature search in four bibliographical databases (Pubmed, CINAHL, EMBASE, and PEDro) was conducted from inception up to February 2015. RCTs were included if participants were workers suffering from RC tendinopathy, the outcome measures included work-related outcomes, and at least one of the interventions under study included exercises. The methodological quality of the studies was evaluated with the Cochrane Risk of Bias Assessment tool.

Results:

The mean methodological score of the ten included studies was 54.4%±17.2%. Types of workers included were often not defined, and work-related outcome measures were heterogeneous and often not validated. Three RCTs of moderate methodological quality concluded that exercises were superior to a placebo or no intervention in terms of function and return-to-work outcomes. No significant difference was found between surgery and exercises based on the results of two studies of low to moderate methodological quality. One study of low methodological quality, comparing a workplace-based exercise program focusing on the participants' work demands to an exercise program delivered in a clinical setting, concluded that the work-based intervention was superior in terms of function and return-to-work outcomes.

Conclusion:

There is low to moderate-grade evidence that therapeutic exercises provided in a clinical setting are an effective modality to treat workers suffering from RC tendinopathy and to promote return-to-work. Further high quality studies comparing different rehabilitation programs including exercises in different settings with defined workers populations are needed to draw firm conclusions on the optimal program to treat workers.

Back schools for acute and subacute non-specific low-back pain

BACKGROUND

Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating people with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today. In this review we defined back school as a therapeutic programme given to groups of people, which includes both education and exercise. This is an update of a Cochrane review first published in 1999, and updated in 2004. For this review update, we split the review into two distinct reviews which separated acute from chronic LBP.

OBJECTIVES

To assess the effectiveness of back schools on pain and disability for people with acute or subacute non-specific LBP. We also examined the effect on work status and adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, PubMed and two clinical trials registers up to 4 August 2015. We also checked the reference lists of articles and contacted experts in the field of research on LBP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that reported on back school for acute or subacute non-specific LBP. The primary outcomes were pain and disability. The secondary outcomes were work status and adverse events. Back school had to be compared with another treatment, a placebo (or sham or attention control) or no treatment.

DATA COLLECTION AND ANALYSIS

We used the 2009 updated method guidelines for this Cochrane review. Two review authors independently screened the references, assessed the quality of the trials and extracted the data. We set the threshold for low risk of bias, a priori, as six or more of 13 internal validity criteria and no serious flaws (e.g. large drop-out rate). We classified the quality of the evidence into one of four levels (high, moderate, low or very low) using the adapted Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

The search update identified 273 new references, of which none fulfilled our inclusion criteria. We included four studies (643 participants) in this updated review, which were all included in the previous (2004) update. The quality of the evidence was very low for all outcomes. As data were too clinically heterogeneous to be pooled, we described individual trial results. The results indicate that there is very low quality evidence that back schools are no more effective than a placebo (or sham or attention control) or another treatment (physical therapies, myofascial therapy, joint manipulations, advice) on pain, disability, work status and adverse events at short-term, intermediate-term and long-term follow-up. There is very low quality evidence that shows a statistically significant difference between back schools and a placebo (or sham or attention control) for return to work at short-term follow-up in favour of back school. Very low quality evidence suggests that back school added to a back care programme is more effective than a back care programme alone for disability at short-term follow-up. Very low quality evidence also indicates that there is no difference in terms of adverse events between back school and myofascial therapy, joint manipulation and combined myofascial therapy and joint manipulation.

AUTHORS' CONCLUSIONS

It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available. While large well-conducted studies will likely provide more conclusive findings, back schools are not widely used interventions for acute and subacute LBP and further research into this area may not be a priority.

Spinal pain: current understanding, trends, and the future of care

This commissioned review paper offers a summary of our current understanding of nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem, requiring management that addresses both the physical and psychosocial components of the pain experience. We propose a model of care that includes the necessary components of care services that would address the multidimensional nature of spinal pain. Emerging care services that tailor care to the individual person with pain seems to achieve better outcomes and greater consumer satisfaction with care, while most likely containing costs. However, we recommend that any model of care and care framework should be developed on the basis of a multidisciplinary approach to care, with the scaffold being the principles of evidence-based practice. Importantly, we propose that any care services recommended in new models or frameworks be matched with available resources and services - this matching we promote as the fourth principle of evidence-based practice. Ongoing research will be necessary to offer insight into clinical outcomes of complex interventions, while practice-based research would uncover consumer needs and workforce capacity. This kind of research data is essential to inform health care policy and practice.

The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis

Objectives

To assess whether cognitive behavioural (CB) approaches improve disability, pain, quality of life and/or work disability for patients with low back pain (LBP) of any duration and of any age.

Methods

Nine databases were searched for randomised controlled trials (RCTs) from inception to November 2014. Two independent reviewers rated trial quality and extracted trial data. Standardised mean differences (SMD) and 95% confidence intervals were calculated for individual trials. Pooled effect sizes were calculated using a random-effects model for two contrasts: CB versus no treatment (including wait-list and usual care (WL/UC)), and CB versus other guideline-based active treatment (GAT).

Results

The review included 23 studies with a total of 3359 participants. Of these, the majority studied patients with persistent LBP (>6 weeks; n=20). At long term follow-up, the pooled SMD for the WL/UC comparison was -0.19 (-0.38, 0.01) for disability, and -0.23 (-0.43, -0.04) for pain, in favour of CB. For the GAT comparison, at long term the pooled SMD was -0.83 (-1.46, -0.19) for disability and -0.48 (-0.93, -0.04) for pain, in favour of CB. While trials varied considerably in methodological quality, and in intervention factors such as provider, mode of delivery, dose, duration, and pragmatism, there were several examples of lower intensity, low cost interventions that were effective.

Conclusion

CB interventions yield long-term improvements in pain, disability and quality of life in comparison to no treatment and other guideline-based active treatments for patients with LBP of any duration and of any age.

Systematic Review Registration

PROSPERO protocol registration number: CRD42014010536.

Shoulder disorders and occupation

Shoulder pain is very common, and it causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins have proved poorly reproducible and hampered epidemiological research. Despite this, there is evidence that exposure to combinations of physical workplace strains such as overhead working, heavy lifting and forceful work as well as working in an awkward posture increases the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently little evidence to suggest that either primary prevention or treatment strategies in the workplace are very effective, and more research is required, particularly around the cost-effectiveness of different strategies.

Long-term effects of interprofessional biopsychosocial rehabilitation for adults with chronic non-specific low back pain: a multicentre, quasi-experimental study

BACKGROUND

Improvement of the long-term effectiveness of multidisciplinary ortho-paedic rehabilitation (MOR) in the management of chronic non-specific low back pain (CLBP) remains a central issue for health care in Germany. We developed an interprofessional and interdisciplinary, biopsychosocial rehabilitation concept named "PASTOR" to promote self-management in adults with CLBP and compared its effectiveness with the current model of MOR.

METHODS

A multicentre quasi-experimental study with three measurement time points was implemented. 680 adults aged 18 to 65 with CLBP were assed for eligibil-ity in three inpatient rehabilitation centres in Germany. At first the effects of the MOR, with a total extent of 48 hours (control group), were assessed. Thereafter, PASTOR was implemented and evaluated in the same centres (intervention group). It consisted of six interprofessional modules, which were provided on 12 days in fixed groups, with a total extent of 48 hours. Participants were assessed with self-report measures at baseline, discharge, and 12 months for functional ability (primary outcome) using the Hannover Functional Ability Questionnaire (FFbH-R) and vari-ous secondary outcomes (e.g. pain, health status, physical activity, pain coping, pain-related cognitions).

RESULTS

In total 536 participants were consecutively assigned to PASTOR (n=266) or MOR (n=270). At 12 months, complete data of 368 participants was available. The adjusted between-group difference in the FFbH-R at 12 months was 6.58 (95% CI 3.38 to 9.78) using complete data and 3.56 (95% CI 0.45 to 6.67) using available da-ta, corresponding to significant small-to-medium effect sizes of d=0.42 (p<0.001) and d=0.10 (p=0.025) in favour of PASTOR. Further improvements in secondary out-comes were also observed in favour of PASTOR.

CONCLUSION

The interprofessional and interdisciplinary, biopsychosocial rehabilita-tion program PASTOR shows some improvements of the long-term effectiveness of inpatient rehabilitation in the management of adults with CLBP. Further insights into mechanisms of action of complex intervention programs are required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02056951.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

BACKGROUND

Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the 'biopsychosocial model', has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.

OBJECTIVES

To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review.

SELECTION CRITERIA

All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds.

DATA COLLECTION AND ANALYSIS

Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity.

MAIN RESULTS

From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions.Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity.

AUTHORS' CONCLUSIONS

Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.

Physiotherapy practice in the private sector: organizational characteristics and models

Background

Even if a large proportion of physiotherapists work in the private sector worldwide, very little is known of the organizations within which they practice. Such knowledge is important to help understand contexts of practice and how they influence the quality of services and patient outcomes. The purpose of this study was to: 1) describe characteristics of organizations where physiotherapists practice in the private sector, and 2) explore the existence of a taxonomy of organizational models.

Methods

This was a cross-sectional quantitative survey of 236 randomly-selected physiotherapists. Participants completed a purpose-designed questionnaire online or by telephone, covering organizational vision, resources, structures and practices. Organizational characteristics were analyzed descriptively, while organizational models were identified by multiple correspondence analyses.

Results

Most organizations were for-profit (93.2%), located in urban areas (91.5%), and within buildings containing multiple businesses/organizations (76.7%). The majority included multiple providers (89.8%) from diverse professions, mainly physiotherapy assistants (68.7%), massage therapists (67.3%) and osteopaths (50.2%). Four organizational models were identified: 1) solo practice, 2) middle-scale multiprovider, 3) large-scale multiprovider and 4) mixed.

Conclusions

The results of this study provide a detailed description of the organizations where physiotherapists practice, and highlight the importance of human resources in differentiating organizational models. Further research examining the influences of these organizational characteristics and models on outcomes such as physiotherapists’ professional practices and patient outcomes are needed.

Low back pain patients' beliefs about effective/ineffective constituents of a counseling intervention: a follow-up interview study

PURPOSE

Everyday activities are important factors for avoiding the development of chronic low back pain (LBP). The purpose this study was to explore LBP patients' perspective on long-term effects of participating in a counseling intervention designed to motivate them to change work routines and to exercise.

METHOD

Follow-up qualitative study. Semi-structured interviews were made of 25 LBP patients who had received the counseling intervention. Interviews were transcribed and explored with an interpretative thematic analysis. The findings were organized around Kleinman's conception of "explanatory models".

RESULTS

For the individual participant the beliefs about the illness were internally coherent, but most often they were idiosyncratic and fitted to the particular participants' overall explanatory model. Participation in the counseling intervention had created a sense of certainty and potential control over the disease and had legitimized their sick role at work and at home. The majority of the patients reported having integrated exercise into their explanatory models and understood exercise to be beneficial in their continual and concrete management of their LBP.

CONCLUSIONS

The intervention had affected the patients' personal agency and space for action. We suggest that this effect was linked to the individually tailored approach drawing on both educational and motivational agents.

IMPLICATIONS FOR REHABILITATION

Maintaining everyday activities, including retaining one's occupation, is an important factor in low back pain rehabilitation. Counselling on low back pain rehabilitation must be aligned with people's beliefs about their illness. A counselling intervention made patients adopt exercising into their long-term management of low back pain.

Interprofessional practices of physiotherapists working with adults with low back pain in Québec's private sector: results of a qualitative study

BACKGROUND

Collaboration and interprofessional practices are highly valued in health systems, because they are thought to improve outcomes of care for persons with complex health problems, such as low back pain. Physiotherapists, like all health providers, are encouraged to take part in interprofessional practices. However, little is known about these practices, especially for private sector physiotherapists. This study aimed to: 1) explore how physiotherapists working in the private sector with adults with low back pain describe their interprofessional practices, 2) identify factors that influence their interprofessional practices, and 3) identify their perceived effects.

METHODS

Participants were 13 physiotherapists, 10 women/3 men, having between 3 and 21 years of professional experience. For this descriptive qualitative study, we used face-to-face semi-structured interviews and conducted content analysis encompassing data coding and thematic regrouping.

RESULTS

Physiotherapists described interprofessional practices heterogeneously, including numerous processes such as sharing information and referring. Factors that influenced physiotherapists' interprofessional practices were related to patients, providers, organizations, and wider systems (e.g. professional system). Physiotherapists mostly viewed positive effects of interprofessional practices, including elements such as gaining new knowledge as a provider and being valued in one's own role, as well as improvements in overall treatment and outcome.

CONCLUSIONS

This qualitative study offers new insights into the interprofessional practices of physiotherapists working with adults with low back pain, as perceived by the physiotherapists' themselves. Based on the results, the development of strategies aiming to increase interprofessionalism in the management of low back pain would most likely require taking into consideration factors associated with patients, providers, the organizations within which they work, and the wider systems.

Identifying and treating the causes of neck pain

Future studies are needed to further understand the pathophysiology of mechanical neck pain. Robust scientific evidence is sparse on which noninvasive treatments are the most beneficial and how to better select patients for particular noninvasive or invasive treatments.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Development of a computer-based clinical decision support tool for selecting appropriate rehabilitation interventions for injured workers

PURPOSE

To develop a classification algorithm and accompanying computer-based clinical decision support tool to help categorize injured workers toward optimal rehabilitation interventions based on unique worker characteristics.

METHODS

Population-based historical cohort design. Data were extracted from a Canadian provincial workers' compensation database on all claimants undergoing work assessment between December 2009 and January 2011. Data were available on: (1) numerous personal, clinical, occupational, and social variables; (2) type of rehabilitation undertaken; and (3) outcomes following rehabilitation (receiving time loss benefits or undergoing repeat programs). Machine learning, concerned with the design of algorithms to discriminate between classes based on empirical data, was the foundation of our approach to build a classification system with multiple independent and dependent variables.

RESULTS

The population included 8,611 unique claimants. Subjects were predominantly employed (85 %) males (64 %) with diagnoses of sprain/strain (44 %). Baseline clinician classification accuracy was high (ROC = 0.86) for selecting programs that lead to successful return-to-work. Classification performance for machine learning techniques outperformed the clinician baseline classification (ROC = 0.94). The final classifiers were multifactorial and included the variables: injury duration, occupation, job attachment status, work status, modified work availability, pain intensity rating, self-rated occupational disability, and 9 items from the SF-36 Health Survey.

CONCLUSIONS

The use of machine learning classification techniques appears to have resulted in classification performance better than clinician decision-making. The final algorithm has been integrated into a computer-based clinical decision support tool that requires additional validation in a clinical sample.

Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain

BACKGROUND

Physical conditioning as part of a return to work strategy aims to improve work status for workers on sick leave due to back pain. This is the second update of a Cochrane Review (originally titled 'Work conditioning, work hardening and functional restoration for workers with back and neck pain') first published in 2003, updated in 2010, and updated again in 2013.

OBJECTIVES

To assess the effectiveness of physical conditioning as part of a return to work strategy in reducing time lost from work and improving work status for workers with back pain. Further, to assess which aspects of physical conditioning are related to a faster return to work for workers with back pain.

SEARCH METHODS

We searched the following databases to March 2012: CENTRAL, MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1982), PsycINFO (from 1967), and PEDro.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and cluster RCTs that studied workers with work disability related to back pain and who were included in physical conditioning programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 41 articles reporting on 25 RCTs with 4404 participants. Risk of bias was low in 16 studies.Three studies involved workers with acute back pain, eight studies workers with subacute back pain, and 14 studies workers with chronic back pain.In 14 studies, physical conditioning as part of a return to work strategy was compared to usual care. The physical conditioning mostly consisted of graded activity with work-related exercises aimed at increasing back strength and flexibility, together with a set date for return to work. The programmes were divided into a light version with a maximum of five sessions, or an intense version with more than five sessions up to full time or as inpatient treatment.For acute back pain, there was low quality evidence that both light and intense physical conditioning programmes made little or no difference in sickness absence duration compared with care as usual at three to 12 months follow-up (3 studies with 340 workers).For subacute back pain, the evidence on the effectiveness of intense physical conditioning combined with care as usual compared to usual care alone was conflicting (four studies with 395 workers). However, subgroup analysis showed low quality evidence that if the intervention was executed at the workplace, or included a workplace visit, it may have reduced sickness absence duration at 12 months follow-up (3 studies with 283 workers; SMD -0.42, 95% CI -0.65 to -0.18).For chronic back pain, there was low quality evidence that physical conditioning as part of integrated care management in addition to usual care may have reduced sickness absence days compared to usual care at 12 months follow-up (1 study, 134 workers; SMD -4.42, 95% CI -5.06 to -3.79). What part of the integrated care management was most effective remained unclear. There was moderate quality evidence that intense physical conditioning probably reduced sickness absence duration only slightly compared with usual care at 12 months follow-up (5 studies, 1093 workers; SMD -0.23, 95% CI -0.42 to -0.03).Physical conditioning compared to exercise therapy showed conflicting results for workers with subacute and chronic back pain. Cognitive behavioural therapy was probably not superior to physical conditioning as an alternative or in addition to physical conditioning.

AUTHORS' CONCLUSIONS

The effectiveness of physical conditioning as part of a return to work strategy in reducing sick leave for workers with back pain, compared to usual care or exercise therapy, remains uncertain. For workers with acute back pain, physical conditioning may have no effect on sickness absence duration. There is conflicting evidence regarding the reduction of sickness absence duration with intense physical conditioning versus usual care for workers with subacute back pain. It may be that including workplace visits or execution of the intervention at the workplace is the component that renders a physical conditioning programme effective. For workers with chronic back pain physical conditioning has a small effect on reducing sick leave compared to care as usual after 12 months follow-up. To what extent physical conditioning as part of integrated care management may alter the effect on sick leave for workers with chronic back pain needs further research.

Effect of peer-based low back pain information and reassurance at the workplace on sick leave: a cluster randomized trial

PURPOSE

To evaluate whether information and reassurance about low back pain (LBP) given to employees at the workplace could reduce sick leave.

METHODS

A Cluster randomized controlled trial with 135 work units of about 3,500 public sector employees in two Norwegian municipalities, randomized into two intervention groups; Education and peer support (EPS) (n = 45 units), education and "peer support and access to an outpatient clinic" (EPSOC) (n = 48 units), and a control group (n = 42 units). Both interventions consisted of educational meetings based on a "non-injury model" and a "peer adviser" appointed by colleagues. Employees in the EPSOC group had access to an outpatient clinic for medical examination and further education. The control group received no intervention. The main outcome was sick leave based on municipal records. Secondary outcomes were self-reported pain, pain related fear of movement, coping, and beliefs about LBP from survey data of 1,746 employees (response rate about 50 %).

RESULTS

EPS reduced sick leave by 7 % and EPSOC reduced sick leave by 4 % during the intervention year, while sick leave in the control group was increased by 7 % during the same period. Overall, Rate Ratios (RR) were statistically significant for EPSOC (RR = .84 (C.I = 0.71-.99) but not EPS (RR = .92 (C.I = 0.78-1.09)) in a mixed Poisson regression analysis. Faulty beliefs about LBP were reduced in both intervention groups.

CONCLUSIONS

Educational meetings, combined with peer support and access to an outpatient clinic, were effective in reducing sick leave in public sector employees.

Can assessing chronic pain outcomes data improve outcomes?

OBJECTIVE

This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes.

DESIGN

Review Manuscript.

SETTING

The clinical management of chronic, non-cancer pain.

SUBJECTS

Adult patients receiving treatment for chronic, non-cancer pain.

RESULTS

While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes.

CONCLUSIONS

Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.