Exercises for prevention of recurrences of low-back pain

How effective are allied health group interventions for the management of adults with long-term conditions? An umbrella review of systematic reviews and its applicability to the Australian primary health system

BACKGROUND

Group allied health interventions for people with chronic conditions may be a solution to increasing access to allied health in primary care. This umbrella review aimed to determine the effectiveness of allied health group interventions to improve health-related outcomes for adults with chronic conditions and the applicability of the findings to the Australian primary health care context.

METHODS

An umbrella review of systematic reviews conducted April-July 2022, searching eight databases. Systematic reviews were eligible if they included randomised controlled trials (RCT) or quasi-RCTs, community dwelling adults aged ≥ 18, at least one chronic condition, group intervention in scope for allied health professionals, and published in English after 2000. Studies were excluded if interventions were conducted in hospital or aged care facilities, out of scope for allied health, or unsupervised.

RESULTS

Two thousand three hundred eighty-five systematic reviews were identified: after screening and full text review 154 were included and data extracted from 90. The chronic conditions included: cancer (n = 15), cardiovascular disease (n = 6), mixed chronic conditions (n = 3), kidney disease (n = 1), low back pain (n = 12), respiratory disease (n = 8), diabetes (n = 14), heart failure (n = 9), risk of falls (n = 5), hypertension (n = 4, osteoarthritis (n = 6) and stroke (n = 8). Most group interventions included prescribed exercise and were in scope for physiotherapists and exercise physiologists. Overall, allied health group exercise programs for community dwelling adults improved health outcomes for most chronic conditions. Aggregated data from the systematic reviews suggests programs of 45-60 min per session, 2-3 times per week for 12 weeks. Lifestyle education and support for people with type-2 diabetes improved glycaemic control.

CONCLUSIONS

Prescribed group exercise delivered by allied health professionals, predominantly by exercise physiologists and physiotherapists, significantly improved health outcomes for community dwelling adults with a broad range of chronic conditions.

Exercises for the prevention of non-specific low back pain

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effects of exercise alone or exercise plus education compared with inactive control or education alone to prevent non-specific LBP.

Exploring barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (MyBack project): a qualitative study

PURPOSE

This study aimed to explore potential barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (LBP).

MATERIALS AND METHODS

Eleven patients, who recovered from a previous episode of LBP, participated in two focus groups. The semi-structured interview schedule was informed by the Behaviour Change Wheel and the Theoretical Domains Framework. Focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis was performed by two researchers independently.

RESULTS

Eighteen barriers and 19 facilitators were identified. The most common barriers included "lack of knowledge on how to manage a recurrence of LBP," "lack of behavioural regulation strategies and having other priorities" and "lack of self-efficacy/confidence to practice exercise autonomously and deal with a new episode of LBP." "Knowledge on exercise and recurrences," "regular exercise habits," "having specific behavioural regulation strategies," "exercise practice with others," "willingness to practice exercise and considering it a priority," and "presence of positive emotions related with exercise practice" were the most common facilitators.

CONCLUSIONS

These findings will inform the development of a behaviour change-informed exercise intervention to promote regular exercise practice among patients at risk of a recurrence of LBP.

MyBack - effectiveness and implementation of a behavior change informed exercise programme to prevent low back pain recurrences: a hybrid effectiveness-implementation randomized controlled study protocol

BACKGROUND

Low back pain (LBP) is a common health condition and the leading cause of years lived with disability worldwide. Most LBP episodes have a favourable prognosis, but recurrences within a year are common. Despite the individual and societal impact related to LBP recurrences, there is limited evidence on effective strategies for secondary prevention of LBP and successful implementation of intervention programmes in a real-world context. The aim of this study is to analyse the effectiveness of a tailored exercise and behavioural change programme (MyBack programme) in the secondary prevention of LBP; and evaluate acceptability, feasibility and determinants of implementation by the different stakeholders, as well as the implementation strategy of the MyBack programme in real context.

METHODS

This protocol describes a hybrid type I, randomized controlled trial to evaluate the effectiveness and implementation of MyBack programme in the context of primary health care. The Behaviour Change Wheel framework and FITT-VP principles will inform the development of the behaviour change and exercise component of MyBack programme, respectively. Patients who have recently recovered from an episode of non-specific LBP will be randomly assigned to MyBack and usual care group or usual care group. The primary outcome will be the risk of LBP recurrence. The secondary outcomes will include disability, pain intensity, musculoskeletal health, and health-related quality of life. Participants will be followed monthly for 1 year. Costs data related to health care use and the MyBack programme will be also collected. Implementation outcomes will be assessed in parallel with the effectiveness study using qualitative methods (focus groups with participants and health providers) and quantitative data (study enrolment and participation data; participants adherence).

DISCUSSION

To our knowledge, this is the first study assessing the effectiveness and implementation of a tailored exercise and behaviour change programme for prevention of LBP recurrences. Despite challenges related to hybrid design, it is expected that data on the effectiveness, cost-effectiveness, and implementation of the MyBack programme may contribute to improve health care in patients at risk of LBP recurrences, contributing to direct and indirect costs reduction for patients and the health system.

TRIAL REGISTRATION NUMBER

NCT05841732.

Research Priorities in the Mechanical Diagnosis and Therapy Among Diploma Therapists: An International Delphi Study

Introduction Mechanical diagnosis and therapy (MDT) is the most researched approach in musculoskeletal physical therapy and involves classifying patients into sub-groups based on their response to loading strategies. MDT diploma therapists (Dip-MDTs) fully recognize the value of MDT in musculoskeletal physical therapy. MDT is updating its system based on the latest research, but the system has not yet been fully established. Therefore, more research is required to increase the comprehensibility of the system. Thus, we aimed to identify future research priorities of MDT. Methods We conducted a modified Delphi study with three rounds. The Research Advisory Committee (RAC) members (n=7) of the McKenzie Institute International were invited to participate in the initial idea generation round. In the subsequent two consensus rounds, Dip-MDTs (n=299) were asked to indicate their level of agreement with the results of the idea generation round using a five-point Likert scale. The criteria for consensus were mean score ≥4.0, coefficient of variation ≤30%, percent agreement ≥75%, and quartile deviation ≤1. A post-hoc analysis of the consensus was conducted when the number of participants from a certain country exceeded one-third of the total number of participants. Results The participation rates for each round were 57.1%, 52.2%, and 49.8%. The USA accounted for 43.6% and 44.3% of all participants at the two consensus rounds, respectively. Finally, nine items reached consensus in the second consensus round. After the post-hoc analysis, eight items reached consensus: (1) cost-effectiveness, (2) cervical and thoracic spine, (3) extremity classifications, (4) filtered randomized controlled trials (RCTs), (5) spinal source classification, (6) centralization and directional preferences, (7) predictive factors for recurrence, and (8) patient education. Conclusion In this study, we identified the research priorities of MDT that would enhance the completion of the MDT system.

Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study

BACKGROUND

Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain.

METHODS

Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements.

RESULTS

In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources.

CONCLUSIONS

This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Comparing the effectiveness of flexi-bar and stability exercises on postural control in chronic nonspecific low back pain: A randomized controlled study

Objectives

This study aimed to compare the effect of flexi-bar and stabilization exercises on static and dynamic postural control in patients with chronic nonspecific low back pain.

Patients and methods

In this randomized controlled study conducted between November 2019 and March 2020, 38 patients (19 males, 19 females; mean age: 33.8±6.2 years; range, 20 to 45 years) were randomly assigned into flexi-bar (n=19) and stabilization (n=19) groups. Both groups received general physiotherapy for three sessions per week, a total of 10 sessions. Besides, the flexi-bar group received flexi-bar exercises, and the stabilization group received stabilization exercises. Postural sway was assessed with a force platform in three difficult conditions, including open eye, close eye, and one-leg standing and dynamic posture with the modified Star Excursion Balance Test.

Results

After the intervention, both groups showed a significant improvement in static and dynamic postural control (p<0.05). However, no significant differences were found between groups after treatment, while only the phase-plane portrait of opened eyes condition was significantly improved (p=0.03), in the flexi-bar group compared to the stabilization group.

Conclusion

Both flexi-bar and stabilization exercises effectively improved static and dynamic postural control, but none of the exercises was superior to the other. Flexi-bar is recommended as an effective tool in low back pain rehabilitation.

Exercise therapy for treatment of acute non-specific low back pain

BACKGROUND

Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many available treatments for LBP include exercise therapy, which is practised extensively worldwide.

OBJECTIVES

To evaluate the benefits and harms of exercise therapy for acute non-specific low back pain in adults compared to sham/placebo treatment or no treatment at short-term, intermediate-term, and long-term follow-up.

SEARCH METHODS

This is an update of a Cochrane Review first published in 2005. We conducted an updated search for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We screened the reference lists of all included studies and relevant systematic reviews published since 2004.

SELECTION CRITERIA

We included RCTs that examined the effects of exercise therapy on non-specific LBP lasting six weeks or less in adults. Major outcomes for this review were pain, functional status, and perceived recovery. Minor outcomes were return to work, health-related quality of life, and adverse events. Our main comparisons were exercise therapy versus sham/placebo treatment and exercise therapy versus no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We evaluated outcomes at short-term follow-up (time point within three months and closest to six weeks after randomisation; main follow-up), intermediate-term follow-up (between nine months and closest to six months), and long-term follow-up (after nine months and closest to 12 months); and we used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 23 studies (13 from the previous review, 10 new studies) that involved 2674 participants and provided data for 2637 participants. Three small studies are awaiting classification, and four eligible studies are ongoing. Included studies were conducted in Europe (N = 9), the Asia-Pacific region (N = 9), and North America (N = 5); and most took place in a primary care setting (N = 12), secondary care setting (N = 6), or both (N = 1). In most studies, the population was middle-aged and included men and women. We judged 10 studies (43%) at low risk of bias with regard to sequence generation and allocation concealment. Blinding is not feasible in exercise therapy, introducing performance and detection bias. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain scores in the short term (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants). The absolute difference was 1% less pain (95% CI 4% more to 6% less), and the relative difference was 4% less pain (95% CI 20% more to 28% less). The mean pain score was 20.1 (standard deviation (SD) 21) for the intervention group and 20.9 (SD 23) for the control group. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on functional status scores in the short term (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants). The absolute difference was 2% worse functional status (95% CI 2% better to 6% worse), and the relative difference was 15% worse (95% CI 17% better to 47% worse). The mean functional status score was 15.3 (SD 19) for the intervention group and 13.3 (SD 18) for the control group. We downgraded the certainty of the evidence for pain and functional status by one level for risk of bias and by two levels for imprecision (only one study with fewer than 400 participants). There is very low-certainty evidence that exercise therapy compared with no treatment has no clinically relevant effect on pain or functional status in the short term (2 studies, 157 participants). We downgraded the certainty of the evidence by two levels for imprecision and by one level for inconsistency. One study associated exercise with small benefits and the other found no differences. The first study was conducted in an occupational healthcare centre, where participants received one exercise therapy session. The other study was conducted in secondary and tertiary care settings, where participants received treatment three times per week for six weeks. We did not pool data from these studies owing to considerable clinical heterogeneity. In two studies, there were no reported adverse events. One study reported adverse events unrelated to exercise therapy. The remaining studies did not report whether any adverse events had occurred. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

AUTHORS' CONCLUSIONS

Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).

Adding a back care package to the primary healthcare; a community-based cluster-randomized trial

Introduction

The clinical course of LBP is complex and chronicity is more frequent than once thought. Moreover, insufficient evidence was found in support of any specific approach at the level of the general population.

Research question

This study aimed to evaluate the effectiveness of providing a back care package through the primary healthcare system in decreasing the rate of CLBP in the community.

Material and methods

Clusters were primary healthcare units with the covered population as participants. The intervention package comprised both exercise and educational content in the form of booklets. Data regarding LBP were collected at baseline, 3 and 9-month follow-ups. The LBP prevalence and the incidence of CLBP in the intervention group compared to the control group were analyzed using logistic regression through GEE.

Results

Eleven clusters were randomized including 3521 enrolled subjects. At 9 months, the intervention group showed a statistically significant decrease in both the prevalence and the incidence of CLBP, compared to the control group (OR ​= ​0.44; 95% CI ​= ​0.30-0.65; P ​< ​0.001 and OR ​= ​0.48; 95% CI ​= ​0.31-0.74; P ​< ​0.001, respectively).

Discussion and conclusion

The population-based intervention was effective in reducing the LBP prevalence and CLBP incidence. Our results suggest that preventing CLBP through a primary healthcare package including exercise and educational content is achievable.

Acute effects of game-based biofeedback training on trunk motion in chronic low back pain: a randomized cross-over pilot trial

BACKGROUND

Improving movement control might be a promising treatment goal during chronic non-specific low back pain (CLBP) rehabilitation. The objective of the study is to evaluate the effect of a single bout of game-based real-time feedback intervention on trunk movement in patients with CLBP.

METHODS

Thirteen CLBP patients (8female;41 ± 16 years;173 ± 10 cm;78 ± 22 kg) were included in this randomized cross-over pilot trial. During one laboratory session (2 h), participants performed three identical measurements on trunk movement all including: first, maximum angle of lateral flexion was assessed. Secondly, a target trunk lateral flexion (angle: 20°) was performed. Main outcome was maximum angle ([°]; MA). Secondary outcomes were deviation [°] from the target angle (angle reproduction; AR) and MA of the secondary movement planes (rotation; extension/flexion) during lateral flexion. The outcomes were assessed by an optical 3D-motion-capture-system (2-segment-trunk-model). The measurements were separated by 12-min of intervention and/or resting (randomly). The intervention involved a sensor-based trunk exergame (guiding an avatar through virtual worlds). After carryover effect-analysis, pre-to-post intervention data were pooled between the two sequences followed by analyses of variances (paired t-test).

RESULTS

No significant change from pre to post intervention for MA or AR for any segment occurred for the main movement plane, lateral flexion (p > .05). The upper trunk segment showed a significant decrease of the MA for trunk extension/flexion from pre to post intervention ((4.4° ± 4.4° (95% CI 7.06-1.75)/3.5° ± 1.29° (95% CI 6.22-0.80); p = 0.02, d = 0.20).

CONCLUSIONS

A single bout of game-based real-time feedback intervention lead to changes in the secondary movement planes indicating reduced evasive motion during trunk movement.

TRIAL REGISTRATION NO

DRKS00029765 (date of registration 27.07.2022). Retrospectively registered in the German Clinical Trial Register.

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews

Background

In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability.

Methods

We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022–01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE.

Results

Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention.

Conclusions

Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources.

Trial registration

PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05722-x.

Implementation initiatives to improve low back pain care in Australia: a scoping review

OBJECTIVE

This scoping review aimed to comprehensively review strategies for implementation of low back pain (LBP) guidelines, policies and models of care in the Australian healthcare system.

METHODS

A literature search was conducted in MEDLINE, EMBASE, CINAHL, Amed and Web of Science to identify studies that aimed to implement or integrate evidence-based interventions/practices to improve LBP care within Australian settings.

RESULTS

Twenty-five studies met the inclusion criteria. Most studies targeted primary care settings (n = 13). Other settings included tertiary care (n = 4), community (n = 4), pharmacies (n = 3). One study targeted both primary and tertiary care settings (n = 1). Only 40% of the included studies reported an underpinning framework, model or theory. Implementation strategies most frequently used were evaluative and iterative strategies (n = 14, 56%) and train and educate stakeholders (n = 13, 52%), followed by engage consumers (n = 6, 24%), develop stakeholder relationships (n = 4, 16%), change in infrastructure (n = 4, 16%) and support clinicians (n = 3, 12%). The most common implementation outcomes considered were acceptability (n = 11, 44%) and adoption (n = 10, 40%), followed by appropriateness (n = 7, 28%), cost (n = 3, 12%), feasibility (n = 1, 4%) and fidelity (n = 1, 4%). Barriers included time constraints, funding, and teamwork availability. Facilitators included funding and collaboration between stakeholders.

CONCLUSIONS

Implementation research targeting LBP appears to be a young field, mostly focusing on training and educating stakeholders in primary care. Outcomes on sustainability and penetration of evidence-based interventions are lacking. There is a need for implementation research guided by established frameworks that consider interrelationships between organisational and system contexts beyond the clinician-patient dyad.

Modifiable lifestyle-related prognostic factors for the onset of chronic spinal pain: A systematic review of longitudinal studies

BACKGROUND

Stratified approaches to spinal pain that address psychosocial risk factors reduce long-term disability to a moderate extent. Identifying and managing other risk factors might help improve outcomes.

OBJECTIVE

This systematic review of longitudinal studies aimed to evaluate possible associations between the onset of chronic spinal pain (including low back, back and neck pain) and putative modifiable lifestyle-related risk or protective factors.

METHODS

This systematic review of longitudinal studies published during the last 2 decades followed PRISMA guidelines. Two reviewers screened Medline, Scopus, Pedro, Cochrane Library, Psycinfo, Science Direct, PTSDpubs and Google Scholar for relevant studies. The QUIPS tool was used to assess the risk of bias. A qualitative meta-synthesis of relevant factors was performed.

RESULTS

Of 3716 unique records, 14 studies met the inclusion criteria (10 with low risk of bias and 4 moderate risk of bias). The highest bias observed was attrition. For chronic low back pain, we found moderate evidence for the involvement of high body weight, waist circumference, and hip circumference and conflicting evidence for high body mass index (BMI), smoking, and physical activity. For chronic neck pain, we found strong evidence for high BMI in women, moderate evidence for sleep disorders in women and conflicting evidence for high BMI in men and physical activity. For chronic back pain, we found limited evidence for gardening/yard work in men and more than one adult at home. Effect sizes were small.

CONCLUSIONS

Several modifiable lifestyle-related factors were identified. Evidence is still sparse and there is a need for more studies. PROSPERO database registration: Ref 172,112 CRD42020172112.

Effect of Six-Week Resistance and Sensorimotor Training on Trunk Strength and Stability in Elite Adolescent Athletes: A Randomized Controlled Pilot Trial

Intervention in the form of core-specific stability exercises is evident to improve trunk stability. The purpose was to assess the effect of an additional 6 weeks sensorimotor or resistance training on maximum isokinetic trunk strength and response to sudden dynamic trunk loading (STL) in highly trained adolescent athletes. The study was conducted as a single-blind, 3-armed randomized controlled trial. Twenty-four adolescent athletes (14f/10 m, 16 ± 1 yrs.;178 ± 10 cm; 67 ± 11 kg; training sessions/week 15 ± 5; training h/week 22 ± 8) were randomized into resistance training (RT; n = 7), sensorimotor training (SMT; n = 10), and control group (CG; n = 7). Athletes were instructed to perform standardized, center-based training for 6 weeks, two times per week, with a duration of 1 h each session. SMT consisted of four different core-specific sensorimotor exercises using instable surfaces. RT consisted of four trunk strength exercises using strength training machines, as well as an isokinetic dynamometer. All participants in the CG received an unspecific heart frequency controlled, ergometer-based endurance training (50 min at max. heart frequency of 130HF). For each athlete, each training session was documented in an individual training diary (e.g., level of SMT exercise; 1RM for strength exercise, pain). At baseline (M1) and after 6 weeks of intervention (M2), participants’ maximum strength in trunk rotation (ROM:63°) and flexion/extension (ROM:55°) was tested on an isokinetic dynamometer (concentric/eccentric 30°/s). STL was assessed in eccentric (30°/s) mode with additional dynamometer-induced perturbation as a marker of core stability. Peak torque [Nm] was calculated as the main outcome. The primary outcome measurements (trunk rotation/extension peak torque: con, ecc, STL) were statistically analyzed by means of the two-factor repeated measures analysis of variance (α = 0.05). Out of 12 possible sessions, athletes participated between 8 and 9 sessions (SMT: 9 ± 3; RT: 8 ± 3; CG: 8 ± 4). Regarding main outcomes of trunk performance, experimental groups showed no significant pre–post difference for maximum trunk strength testing as well as for perturbation compensation (p &gt; 0.05). It is concluded, that future interventions should exceed 6 weeks duration with at least 2 sessions per week to induce enhanced trunk strength or compensatory response to sudden, high-intensity trunk loading in already highly trained adolescent athletes, regardless of training regime.

Facing the National Recovery and Resilience Plan: Sources of Data, Indicators, and Participatory Strategies in Healthcare and Social Fields

Innovation in governance and services should be the target of the Italian National Recovery and Resilience Plan. Monitoring processes, impacts, and outcomes requires a system of new indicators that are practical to collect. Secondary data sources, their availability, and their information potential should be evaluated, and primary sources should be implemented to supplement traditional disease surveillance. This work highlights the most relevant aspects for bridging the mismatching between complex community needs and current health/social supply and how those aspects could be faced. As a result, we propose a structured multi-phases process for setting the design and functionalities of a cooperative information system, built on the integration between secondary and primary data for informing policies about chronic low back pain (CLBP), a widely recognized determinant of disability and significant economic burden. In particular, we propose the Dress-KINESIS, a tool for improving community capacity development and participation that allows one to freely collect big health and social data and link it to existing secondary data. The system also may be able to monitor how the resources are distributed across different care sectors and suggest how to improve efficiency based on the patient’s CLBP risk stratification. Moreover, it is potentially customizable in other fields of health.

Medical exercise and physiotherapy modes and frequency as predictors for a recurrence of chronic non-specific low back pain

BACKGROUND

A considerable part of patients with non-specific low back pain (LBP) suffer from a recurrence of symptoms after therapy cessation.

OBJECTIVE

The aim of this cohort study was to evaluate the predictive value of active and passive treatments and treatment modalities on a recurrence of low back pain after cessation of medically prescribed therapy.

METHODS

Patients with non-specific LBP from a health- and therapy-center were included. Treatments were monitored and categorized as active or passive. During one year after therapy cessation, patients were monitored to retrieve information about recurrence of symptoms. Patients were dichotomized (recurrence versus no recurrence). An ROC-Analysis was used to determine optimal cut-offs for relevant treatment characteristics' (passive versus active; frequency) impact on recurrence risk. The relative risk for a recurrence was calculated based on Chi2-test.

RESULTS

Data from 96 participants (56 females, 40 males, mean age 49 years, standard deviation 11 years) were analysed. A total of 34 participants had recurring LBP. The frequency of active treatment differed significantly between groups with or without recurrence (p< 0.05). A therapy frequency of 1.45 active treatments/week was a sensitive cut-off (sensitivity: 0.73) to discriminate the recurrence groups. Participants with an active therapy frequency of less than 1.45 treatments per week showed an 82% increased relative recurrence risk (RR: 1.824 (95%-CI: 1.077-3.087)).

CONCLUSIONS

The results empathize the importance of active treatments (i.e. exercise) in the therapy and (secondary) prevention of non-specific LBP. Less than 1.45 active treatment sessions/week increases the 1-year-risk of a recurrence by 82%. Performing at least two treatments sessions per week is therefore recommended.

Sustainability of a Motor Control Exercise Intervention: Analysis of Long-Term Effects in a Low Back Pain Study

Development of chronic pain after a low back pain episode is associated with increased pain sensitivity, altered pain processing mechanisms and the influence of psychosocial factors. Although there is some evidence that multimodal therapy (such as behavioral or motor control therapy) may be an important therapeutic strategy, its long-term effect on pain reduction and psychosocial load is still unclear. Prospective longitudinal designs providing information about the extent of such possible long-term effects are missing. This study aims to investigate the long-term effects of a homebased uni- and multidisciplinary motor control exercise program on low back pain intensity, disability and psychosocial variables. 14 months after completion of a multicenter study comparing uni- and multidisciplinary exercise interventions, a sample of one study center (n = 154) was assessed once more. Participants filled in questionnaires regarding their low back pain symptoms (characteristic pain intensity and related disability), stress and vital exhaustion (short version of the Maastricht Vital Exhaustion Questionnaire), anxiety and depression experiences (the Hospital and Anxiety Depression Scale), and pain-related cognitions (the Fear Avoidance Beliefs Questionnaire). Repeated measures mixed ANCOVAs were calculated to determine the long-term effects of the interventions on characteristic pain intensity and disability as well as on the psychosocial variables. Fifty four percent of the sub-sample responded to the questionnaires (n = 84). Longitudinal analyses revealed a significant long-term effect of the exercise intervention on pain disability. The multidisciplinary group missed statistical significance yet showed a medium sized long-term effect. The groups did not differ in their changes of the psychosocial variables of interest. There was evidence of long-term effects of the interventions on pain-related disability, but there was no effect on the other variables of interest. This may be partially explained by participant's low comorbidities at baseline. Results are important regarding costless homebased alternatives for back pain patients and prevention tasks. Furthermore, this study closes the gap of missing long-term effect analysis in this field.

Back to living well: community-based management of low back pain: a feasibility study

BACKGROUND

Low back pain (LBP) is a long-term health condition with an unpredictable pattern of symptomatic episodes, remission, and recurrence. Recently published systematic reviews suggest that exercise is the most effective intervention for preventing recurrences of LBP in persons that have recovered. Similar programs may also be effective in preventing flare-ups in persistent LBP. The aim of this study was to test the feasibility of the Back to Living Well program (Physical activity + Education + Self-management) developed to prevent recurrence or flare-ups of LBP. The study evaluated feasibility in terms of recruitment rate, adherence, satisfaction with the exercise and education sessions, and the data collection procedures. We also aimed to evaluate barriers and facilitators to the engagement in the program.

METHODS

Seventeen participants with non-specific LBP recently discharged from care from physiotherapy, chiropractors or physician care (< 3 months) were referred to the study by health care providers or community advertisements between December 2018 and February 2019. Participants underwent a 12-week (1 session/week) individualized, group-based exercise in the community and 4 sessions (30 min each) of education. All participants completed an action plan weekly for 12 weeks and wore an activity monitor for 6 months. All participants responded to weekly pain measures and completed study questionnaires at baseline, 3- and 6-months. Feasibility outcomes included recruitment, attrition rates and satisfaction. At the end of the intervention, participants completed an end-of-program survey.

RESULTS

Twenty-nine participants were screened for eligibility; 20 were deemed eligible, while 17 were included over a 2-month period meeting our feasibility targets. In total, 16 completed follow-up study questionnaires at 3 months, and 15 completed the 6-month follow-up. Fourteen participants responded to weekly messages, while 3 participants reported not having a mobile device or Internet access. In total, 15 participants responded to our end-of-program survey. Average age was 54.9 (11.7); 9 were female (53%), and the mean duration of LBP was 62.9 (69.7) months. All satisfaction responses in relation to the exercise program, education program and data collection procedures reached our threshold of 70% out of 100%. Reported barriers to engagement in the program included fear of injury, lack of motivation and travel. Facilitators included proximity to home, low cost, flexible schedule and friendly location.

CONCLUSION

The results show the program is feasible in terms of recruitment, low attrition, and patient satisfaction. Participants highlighted the excellent, relevant education program and the positive, personalized exercise. Future studies should evaluate the effectiveness of this intervention within a fully powered randomized controlled trial.

TRIAL REGISTRATION

NCT03328689.

Effectiveness of training in guideline-oriented biopsychosocial management of low-back pain in occupational health services - a cluster randomized controlled trial

Objective:

This study aimed to investigate the effectiveness of brief training in the guideline-oriented biopsychosocial management of low-back pain (LBP) in occupational health services using a cluster-randomized design. A small sample of physiotherapists and physicians from the intervention units (N=12) were given three- to seven-day training focusing on the biopsychosocial management of LBP, while professionals in the control units (N=15) received no such training.

Methods:

Eligible patients with LBP, with or without radicular pain, aged 18–65, were invited to participate. A web-based questionnaire was sent to all recruited patients at baseline, three months and one year. The primary outcome measure was disability (Oswestry Disability Index, ODI) over one year. Between-group differences were analyzed using linear and generalized linear mixed models adjusted for baseline-response delay as well as variables showing between-group imbalance at baseline.

Results:

The final study sample comprised 234 and 81 patients in the intervention and control groups, respectively at baseline, and 137 and 47 patients, respectively, at one year. At baseline, the mean duration of pain was longer in the intervention group (P=0.017), and pain-related fear concerning physical activity was lower (P=0.012). We observed no significant difference between the groups’ primary outcome measure (adjusted one-year mean difference in the ODI: 2.3; 95% confidence interval -1.0–5.7; P=0.175) or most secondary outcomes.

Conclusions:

Brief training in guideline-oriented biopsychosocial management of LBP for occupational health professionals did not appear to be effective in reducing patients’ symptom over one-year follow-up compared to treatment as usual.

Evaluation of training in guideline-oriented biopsychosocial management of low back pain in occupational health services: Protocol of a cluster randomized trial

BACKGROUND

To prevent low back pain (LBP) from developing into a prolonged disabling condition, clinical guidelines advocate early stage assessment, risk-screening, and tailored interventions. Occupational health services recommend guideline-oriented biopsychosocial screening and individualized assessment and management. However, it is not known whether training a limited number of health care professionals improves the management process. The primary objective of this study is to investigate whether training in the biopsychosocial practice model is effective in reducing disability. Furthermore, we aim to evaluate health-economic impacts of the training intervention in comparison to usual medical care.

METHODS

The occupational health service units will be allocated into a training or control arm in a two-arm cluster randomized controlled design. The training of occupational physiotherapists and physicians will include the assessment of pain-related psychosocial factors using the STarT Back Tool and the short version of the Örebro Musculoskeletal Pain Screening Questionnaire, the use of an evidence-based patient education booklet as part of the management of LBP, and tailored individualized management of LBP according to risk stratification. The control units will receive no training. The study population will include patients aged 18-65 with nonspecific LBP. The primary outcome is a patient-reported Oswestry Disability Index from baseline to 12 months. By estimating group differences over time, we aim to evaluate the effectiveness of the training intervention in comparison to usual medical care, and to undertake an economic evaluation using individual patients' health care records (participant-level data) and the participating units' registries (cluster-level data). In addition, through interviews and questionnaires, we will explore the health care professionals' conceptions of the adoption of, the barriers to, and the facilitators of the implementation of the practice model.

DISCUSSION

The evaluation of training in the guideline-oriented biopsychosocial management of LBP in occupational health services is justified because LBP represents an enormous burden in terms of work disability.

Acupuncture for the Management of Low Back Pain

PURPOSE OF REVIEW

This evidence-based systematic review will focus on the use of acupuncture and its role in the treatment of low back pain to help better guide physicians in their practice. It will cover the background and the burden of low back pain and present the current options for treatment and weigh the evidence that is available to support acupuncture as a treatment modality for low back pain.

RECENT FINDINGS

Low back pain (LBP), defined as a disorder of the lumbosacral spine and categorized as acute, subacute, or chronic, can be a debilitating condition for many patients. Chronic LBP is more typically defined by its chronicity with pain persisting > 12 weeks in duration. Conventional treatment for chronic LBP includes both pharmacologic and non-pharmacologic options. First-line pharmacologic therapy involves the use of NSAIDs, then SNRI/TCA/skeletal muscle relaxants, and antiepileptics. Surgery is usually not recommended for chronic non-specific LBP patients. According to the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain and the 2017 American College of Physicians (ACP) clinical practice guidelines for chronic pain, non-pharmacologic interventions, acupuncture can be a first-line treatment for patients suffering from chronic low back pain. Many studies have been done, and most show promising results for acupuncture as an alternative treatment for low back pain. Due to non-standardized methods for acupuncture with many variations, standardization remains a challenge.

Occupational Related Upper and Low Back Pain Among the Working Population of Ethiopia: Systematic Review and Meta-Analysis

BACKGROUND

Back pain, such as upper and low back pain are among the most common musculoskeletal conditions that can cause major public health and socioeconomic problems. Back pain is one of the leading causes of disability that reduces worker performance and well-being and increases absence from work, which can cause an enormous economic burden. In developing countries, particularly in Ethiopia, there is no adequate evidence on the overall prevalence of occupational-related upper and low back pain, and they remain less prioritized and empirically unrepresented. Therefore, this study aimed to determine the prevalence of occupational-related upper and low back pain among the working population of Ethiopia.

METHODS

This systematic review and meta-analysis considered studies conducted in Ethiopia, written in English, and published from 2017 to 2020. Articles were searched from 9 electronic databases (Web of Science, SCOPUS, PubMed, Google Scholar, CINAHL, Cochrane Library, African Index Medicus, African Journals Online database, and Science Direct) using a combination of Boolean logic operators, Medical Subject Headings, and main keywords. The quality assessment of the articles was performed using the Joanna Briggs Institute Critical Appraisal tools to determine the relevance of the articles to the study. A random effects model was used to estimate the pooled prevalence, the 95% confidence interval, and the degree of heterogeneity among the included studies. Sensitivity analyses were performed to identify the influence of outliers and to identify sources of heterogeneity.

RESULTS

Of the 1114 studies identified from the included databases, 20 studies were included in the systematic review and meta-analysis. The pooled prevalence of occupational-related upper and low back pain in the previous year was (27.1% [95% CI: 18.4, 37.9]) and (54.2% [95% CI: 48.2, 60.0]), respectively. Based on a subgroup analysis by publication year, study population, and regions where the studies were conducted, the prevalence of upper back pain was (43.8% [95% CI: 39.3, 47.7]), (34.7% [95% CI: 33.1, 36.2]), and (36.2% [95% CI: 33.6, 39.0]), respectively, while the prevalence of low back pain was (61.8% [95% CI: 58.9, 64.6], (52.8% [95% CI: 51.3, 54.3]), and (55.2% [95% CI: 51.4, 59.0]), respectively.

CONCLUSIONS

This systematic review and meta-analysis found that 54.2% of the included study participants experienced low back pain in the previous year, while 27.1% experienced upper back pain. The highest prevalence was reported among pedestrian back-loading women.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Dose-response-relationship of stabilisation exercises in patients with chronic non-specific low back pain: a systematic review with meta-regression

Stabilization exercise (SE) is evident for the management of chronic non-specific low back pain (LBP). The optimal dose-response-relationship for the utmost treatment success is, thus, still unknown. The purpose is to systematically review the dose-response-relationship of stabilisation exercises on pain and disability in patients with chronic non-specific LBP. A systematic review with meta-regression was conducted (Pubmed, Web of Knowledge, Cochrane). Eligibility criteria were RCTs on patients with chronic non-specific LBP, written in English/German and adopting a longitudinal core-specific/stabilising/motor control exercise intervention with at least one outcome for pain intensity and/or disability. Meta-regressions (dependent variable = effect sizes (Cohens d) of the interventions (for pain and for disability), independent variable = training characteristics (duration, frequency, time per session)), and controlled for (low) study quality (PEDro) and (low) sample sizes (n) were conducted to reveal the optimal dose required for therapy success. From the 3,415 studies initially selected, 50 studies (n = 2,786 LBP patients) were included. N = 1,239 patients received SE. Training duration was 7.0 ± 3.3 weeks, training frequency was 3.1 ± 1.8 sessions per week with a mean training time of 44.6 ± 18.0 min per session. The meta-regressions' mean effect size was d = 1.80 (pain) and d = 1.70 (disability). Total R² was 0.445 and 0.17. Moderate quality evidence (R² = 0.231) revealed that a training duration of 20 to 30 min elicited the largest effect (both in pain and disability, logarithmic association). Low quality evidence (R² = 0.125) revealed that training 3 to 5 times per week led to the largest effect of SE in patients with chronic non-specific LBP (inverted U-shaped association). In patients with non-specific chronic LBP, stabilization exercise with a training frequency of 3 to 5 times per week (Grade C) and a training time of 20 to 30 min per session (Grade A) elicited the largest effect on pain and disability.

External and Total Hip Rotation Ranges of Motion Predispose to Low Back Pain in Elite Spanish Inline Hockey Players

Low back pain (LBP) is a common ailment in competitive athletes. Although the association between limited range of motion (ROM) and prevalence of LBP has been widely investigated in other sports, there is no research about this topic in inline hockey (IH). The main purposes of this study in IH players were (1) to analyze the association between hip ROM and LBP and (2) to establish a diagnostic cutoff for ROM of high risk of LBP. Twenty elite IH players from the two Spanish National Teams (male and female) were assessed for passive maximum hip ROMs; the movement evaluated were the hip external [HER] and internal [HIR] rotation, hip flexion with flexed [HF-KF] and extended [HF-KE] knee, hip adduction with flexed hip [HAD-HF], hip abduction with neutral [HAB] and flexed [HAB-HF] hip, and hip extension [HE]. LBP was retrospectively monitored for the last 12 months before the date of ROM assessment by using a questionnaire. The data were analyzed via a binary logistic regression and receiver operating characteristic curves. The 70% of players had developed LBP during the retrospective study period. Significant differences between LBP group and asymptomatic group for HER (p = 0.013, d [Cohen’s effect size] = 1.17) and hip total rotation [HTR] (p = 0.032, d [Cohen’s effect size] = 1.05) were observed. The cutoff points with the greatest discriminatory capacity were 56.5° for HER and 93° for HTR ROMs.

Fear-avoidance beliefs are associated with exercise adherence: secondary analysis of a randomised controlled trial (RCT) among female healthcare workers with recurrent low back pain

Background

Exercise is recommended for the treatment and management of low back pain (LBP) and the prevention of chronicity. Exercise adherence has been only modest in intervention studies among people with musculoskeletal pain. Fear-avoidance beliefs (FABs) are known to affect exercise adherence.

The purpose was twofold: to examine which bio-psycho-social factors contributed to exercise adherence during a 6-month neuromuscular exercise intervention among female healthcare workers with recurrent LBP, and to investigate how exercising affects FABs at 6 and 12 months’ follow-up.

Methods

Some 219 healthcare workers aged 30–55 years with mild-to-moderate re-current non-specific LBP were originally allocated into: 1) exercise, 2) counselling, 3) combined exercise and counselling, and 4) control groups. In the present secondary analysis, groups 1 and 3 (exercise only and exercise+counselling) were merged to be exercisers and groups 2 and 4 were merged to be non-exercisers. Baseline variables of the exercise compliers (≥24 times over 24 weeks; n = 58) were compared to those of the non-compliers (< 1 time/week, 0–23 times; n = 52). The effects of the exercise programme on FABs were analysed by a generalised linear mixed model according to the intention-to-treat principle (exercisers; n = 110 vs non-exercisers; n = 109) at three measurement points (baseline, 6, and 12 months). A per-protocol analysis compared the more exercised to the less exercised and non-exercisers.

Results

A low education level (p = 0.026), shift work (p = 0.023), low aerobic (p = 0.048) and musculoskeletal (p = 0.043) fitness, and high baseline physical activity-related FABs (p = 0.019) were related to low exercise adherence. The exercise programme reduced levels of both physical activity- and work-related FABs, and there was a dose response: FABs reduced more in persons who exercised ≥24 times compared to those who exercised 0–23 times.

Conclusion

Healthcare workers who had lower education and fitness levels, worked shifts, and had high physical activity-related FABs had a lower adherence to the 6-month neuromuscular exercise programme. Exercising with good adherence reduced levels of FABs, which have been shown to be linked with prolonged LBP. Motivational strategies should be targeted at persons with low education and fitness levels and high FABs in order to achieve better exercise adherence.

Effectiveness and cost-effectiveness of stratified blended physiotherapy in patients with non-specific low back pain: study protocol of a cluster randomized controlled trial

BACKGROUND

Patient education, advice on returning to normal activities and (home-based) exercise therapy are established treatment options for patients with non-specific low back pain (LBP). However, the effectiveness of physiotherapy interventions on physical functioning and prevention of recurrent events largely depends on patient self-management, adherence to prescribed (home-based) exercises and recommended physical activity behaviour. Therefore we have developed e-Exercise LBP, a blended intervention in which a smartphone application is integrated within face-to-face care. E-Exercise LBP aims to improve patient self-management skills and adherence to exercise and physical activity recommendations and consequently improve the effectiveness of physiotherapy on patients' physical functioning. The aim of this study is to investigate the short- (3 months) and long-term (12 and 24 months) effectiveness on physical functioning and cost-effectiveness of e-Exercise LBP in comparison to usual primary care physiotherapy in patients with LBP.

METHODS

This paper presents the protocol of a prospective, multicentre cluster randomized controlled trial. In total 208 patients with LBP pain were treated with either e-Exercise LBP or usual care physiotherapy. E-Exercise LBP is stratified based on the risk for developing persistent LBP. Physiotherapists are able to monitor and evaluate treatment progress between face-to-face sessions using patient input from the smartphone application in order to optimize physiotherapy care. The smartphone application contains video-supported self-management information, video-supported exercises and a goal-oriented physical activity module. The primary outcome is physical functioning at 12-months follow-up. Secondary outcomes include pain intensity, physical activity, adherence to prescribed (home-based) exercises and recommended physical activity behaviour, self-efficacy, patient activation and health-related quality of life. All measurements will be performed at baseline, 3, 12 and 24 months after inclusion. An economic evaluation will be performed from the societal and the healthcare perspective and will assess cost-effectiveness of e-Exercise LBP compared to usual physiotherapy at 12 and 24 months.

DISCUSSION

A multi-phase development and implementation process using the Center for eHealth Research Roadmap for the participatory development of eHealth was used for development and evaluation. The findings will provide evidence on the effectiveness of blended care for patients with LBP and help to enhance future implementation of blended physiotherapy.

TRIAL REGISTRATION

ISRCTN, ISRCTN94074203. Registered 20 July 2018 - Retrospectively registered.

Sustainability effects of motor control stabilisation exercises on pain and function in chronic nonspecific low back pain patients: A systematic review with meta-analysis and meta-regression

Study design

Systematic review with meta-analysis and meta-regression.

Background and objectives

We systematically reviewed and delineated the existing evidence on sustainability effects of motor control exercises on pain intensity and disability in chronic low back pain patients when compared with an inactive or passive control group or with other exercises. Secondary aims were to reveal whether moderating factors like the time after intervention completion, the study quality, and the training characteristics affect the potential sustainability effects.

Methods

Relevant scientific databases (Medline, Web of Knowledge, Cochrane) were screened. Eligibility criteria for selecting studies: All RCTs und CTs on chronic (≥ 12/13 weeks) nonspecific low back pain, written in English or German and adopting a longitudinal core-specific/stabilizing sensorimotor control exercise intervention with at least one pain intensity and disability outcome assessment at a follow-up (sustainability) timepoint of ≥ 4 weeks after exercise intervention completion.

Results and conclusions

From the 3,415 studies that were initially retrieved, 10 (2 CTs & 8 RCTs) on N = 1081 patients were included in the review and analyses. Low to moderate quality evidence shows a sustainable positive effect of motor control exercise on pain (SMD = -.46, Z = 2.9, p < .001) and disability (SMD = -.44, Z = 2.5, p < .001) in low back pain patients when compared to any control. The subgroups’ effects are less conclusive and no clear direction of the sustainability effect at short versus mid versus long-term, of the type of the comparator, or of the dose of the training is given. Low quality studies overestimated the effect of motor control exercises.

Association between lifestyle and musculoskeletal pain: cross-sectional study among 10,000 adults from the general working population

BACKGROUND

Work-related musculoskeletal pain is a major cause of work disability and sickness absence. While pain is a multifactorial phenomenon being influenced by work as well as lifestyle, less is known about the association between specific lifestyle factors and the type of musculoskeletal pain. The aim of the study was to investigate if a dose-response association existed between lifestyle factors and musculoskeletal pain intensity in the low back and neck-shoulder.

METHODS

Currently employed wage earners (N = 10,427) replied in 2010 to questions about work environment, lifestyle and health. Logistic regression analyses adjusted for various confounders tested the association of alcohol intake, physical activity, fruit and vegetable intake, and smoking (explanatory variables) with low back pain and neck-shoulder pain intensity (outcomes variables, scale 0-9, where ≥4 is high pain).

RESULTS

The minimally adjusted model found that physical activity and fruit and vegetable intake were associated with lower risk of musculoskeletal pain, while smoking was associated with higher risk of musculoskeletal pain. In the fully adjusted model, physical activity ≥5 h per week was associated with lower risk of low back pain and neck-shoulder pain with risk ratios (RR) of 0.95 (95% CI 0.90-1.00) and 0.90 (95% CI 0.82-0.99), respectively. No association was found between alcohol intake and pain.

CONCLUSION

Being physically active associated with lower risk of having musculoskeletal pain, while smoking habits and healthy eating were associated with higher pain when adjusting for age and gender. Considering the continuously increasing retirement age in many societies, initiatives to promote healthy habits should still be a political priority to help the workers to stay healthy and cope to their work.

Association between low back pain and various everyday performances : Activities of daily living, ability to work and sexual function

Low back pain (LBP) is a widely prevalent chronic pain disorder associated with a high burden on individuals and society. In the subjective perception of patients with LBP, probably the most important health outcomes associated with LBP are those that effect everyday performance. Such outcomes include reduction in activities of daily living (ADL), in work ability (WA), and in sexual function. This narrative review aimed to (1) examine the association between LBP and the three mentioned outcomes of everyday performance, (2) to explain possible mediating factors promoting these associations, and (3) to discuss possible implications for treatment and rehabilitation. Studies have shown that LBP can generate anxiety of movement leading to movement avoidance (fear-avoidance beliefs), which may lead to deconditioning and further increasing problems with ADL, WA and decreasing sexual function. Furthermore, common mental disorders, such as depression, anxiety, and stress-related disorders, which also often co-occur with LBP can lead to adverse effects on everyday performance and vice versa, can be the consequence of such problems and aggravate LBP. Although there is no universally accepted treatment modality that fits every patient with LBP, physical training, comprehensive patient education, and workplace or home modifications have been shown to be able to interrupt the mutual influence between LBP and the described mediating factors, and have a beneficial effect on ADL, WA, and sexual function. For this, a multidisciplinary approach is necessary which includes multiprofessional care teams, participation of the patients, and involvement of different settings, such as workplace, home, and physical training facilities.

Early occupational intervention for people with low back pain in physically demanding jobs: A randomized clinical trial

BACKGROUND

Occupational medicine seeks to reduce sick leave; however, evidence for an add-on effect to usual care is sparse. The objective of the GOBACK trial was to test whether people with low back pain (LBP) in physically demanding jobs and at risk of sick leave gain additional benefit from a 3-month complex intervention that involves occupational medicine consultations, a work-related evaluation and workplace intervention plan, an optional workplace visit, and a physical activity program, over a single hospital consultation and an MRI.

METHODS AND FINDINGS

We enrolled people from the capital region of Denmark to an open-label, parallel-group randomized controlled trial with a superiority design from March 2014 through December 2015. In a hospital setting 305 participants (99 women) with LBP and in physically demanding jobs were randomized to occupational intervention (n = 153) or no additional intervention (control group; n = 152) added to a single hospital consultation giving a thorough explanation of the pain (i.e., clinical examination and MRI) and instructions to stay active and continue working. Primary outcome was accumulated sick leave days due to LBP during 6 months. Secondary outcomes were changes in neuropathic pain (painDETECT questionnaire [PDQ]), pain 0-10 numerical rating scale (NRS), Fear-Avoidance Beliefs Questionnaire (FABQ), Roland-Morris Disability Questionnaire (RMDQ), Short Form Health Survey (SF-36) for physical and mental health-related quality of life (HRQoL), and self-assessed ability to continue working (range 0-10). An intention-to-treat analysis of sick leave at 6 months showed no significant difference between groups (mean difference in days suggestively in favor of no additional intervention: 3.50 [95% CI -5.08 to 12.07], P = 0.42). Both groups showed significant improvements in average pain score (NRS), disability (RMDQ), fear-avoidance beliefs about physical activities and work (FABQ), and physical HRQoL (SF-36 physical component summary); there were no significant differences between the groups in any secondary outcome. There was no statistically significant improvement in neuropathic pain (PDQ score), mental HRQoL (SF-36 mental component summary), and self-assessed ability to stay in job. Four participants could not complete the MRI or the intervention due to a claustrophobic attack or accentuated back pain. Workplace visits may be an important element in the occupational intervention, although not always needed. A per-protocol analysis that included the 40 participants in the intervention arm who received a workplace visit as part of the additional occupational intervention did not show an add-on benefit in terms of sick leave (available cases after 6 months, mean difference: -0.43 days [95% CI -12.8 to 11.94], P = 0.945). The main limitations were the small number of sick leave days taken and that the comprehensive use of MRI may limit generalization of the findings to other settings, for example, general practice.

CONCLUSIONS

When given a single hospital consultation and MRI, people in physically demanding jobs at risk of sick leave due to LBP did not benefit from a complex additional occupational intervention. Occupational interventions aimed at limiting biopsychological obstacles (e.g., fear-avoidance beliefs and behaviors), barriers in the workplace, and system barriers seem essential to reduce sick leave in patients with LBP. This study indicates that these obstacles and barriers may be addressed by thorough usual care.

TRIAL REGISTRATION

Clinical Trials.gov: NCT02015572.

Neuromuscular exercise reduces low back pain intensity and improves physical functioning in nursing duties among female healthcare workers; secondary analysis of a randomised controlled trial

Background

Low back pain (LBP) is common among healthcare workers, whose work is physically strenuous and thus demands certain levels of physical fitness and spinal control. Exercise is the most frequently recommended treatment for LBP. However, exercise interventions targeted at sub-acute or recurrent patients are scarce compared to those targeted at chronic LBP patients. Our objective was to examine the effects of 6 months of neuromuscular exercise on pain, lumbar movement control, fitness, and work-related factors at 6- and 12-months’ follow-up among female healthcare personnel with sub-acute or recurrent low back pain (LBP) and physically demanding work.

Methods

A total of 219 healthcare workers aged 30–55 years with non-specific LBP were originally allocated to four groups (exercise, counselling, combined exercise and counselling, control). The present study is a secondary analysis comparing exercisers (n = 110) vs non-exercisers (n = 109). Exercise was performed twice a week (60 min) in three progressive stages focusing on controlling the neutral spine posture. The primary outcome was intensity of LBP. Secondary outcomes included pain interfering with work, lumbar movement control, fitness components, and work-related measurements. Between-group differences were analysed with a generalised linear mixed model according to the intention-to-treat principle. Per-protocol analysis compared the more exercised to the less exercised and non-exercisers.

Results

The mean exercise attendance was 26.3 (SD 12.2) of targeted 48 sessions over 24 weeks, 53% exercising 1–2 times a week, with 80% (n = 176) and 72% (n = 157) participating in 6- and in 12-month follow-up measurements, respectively. The exercise intervention reduced pain (p = 0.047), and pain interfering with work (p = 0.046); improved lumbar movement control (p = 0.042), abdominal strength (p = 0.033) and physical functioning in heavy nursing duties (p = 0.007); but had no effect on other fitness and work-related measurements when compared to not exercising. High exercise compliance resulted in less pain and better lumbar movement control and walking test results.

Conclusion

Neuromuscular exercise was effective in reducing pain and improving lumbar movement control, abdominal strength, and physical functioning in nursing duties compared to not exercising.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2678-x) contains supplementary material, which is available to authorized users.

Prevalence of work-related musculoskeletal disorders and ergonomic practice among dentists in Jeddah, Saudi Arabia

Background

Musculoskeletal disorders (MSD) is the second most common cause of disability. MSD due to the occupation are called work-related musculoskeletal disorders (WMSD) and are common among dentists.

Objective

Assess the prevalence of self-reported work-related musculoskeletal disorders (WMSD) and to identify associated ergonomic practice among dentists practicing in Jeddah City, Saudi Arabia.

Methods

Dentists practicing in Jeddah were invited to participate in this cross-sectional study using a self-administered survey. The survey consisted of 20 close-ended questions. The survey included questions regarding demographics, dental practice, general health status, exercising, ergonomic practice, musculoskeletal pain location, the severity of pain using a numeric pain rating scale (0–10), interventions sought, and missed work due to WMSD.

Results

A sample of 234 dentists participated in this study. Prevalence of WMSD was found to be 70%. The most common location for WMSD pain was in the low back (85%) and neck (84.6%). Female dentists and dentists not exercising regularly had an increased risk of WMSD. The prevalence of CTS was 9%, and its risk increased with age and practicing in the private sector. Among the dental specialties, the least to report WMSD or CTS were maxillofacial surgeons and orthodontists. The reported ergonomic practice reached as low as 24%.

Conclusion

Work-related musculoskeletal disorders and inadequate ergonomic practices were common. Ergonomics training intervention programs targeting dentists is suggested as a preventive measure for longer and healthier career lives.

Lifestyle factors and risk of sickness absence from work: a multicohort study

Background

Lifestyle factors influence the risk of morbidity and mortality, but the extent to which they are associated with employees' absence from work due to illness is unclear. We examined the relative contributions of smoking, alcohol consumption, high body-mass index, and low physical activity to diagnosis-specific sickness absence.

Methods

We did a multicohort study with individual-level data of participants of four cohorts from the UK, France, and Finland. Participants' responses to a lifestyle survey were linked to records of sickness absence episodes, typically lasting longer than 9 days; for each diagnostic category, the outcome was the total number of sickness absence days per year. We estimated the associations between lifestyle factors and sickness absence by calculating rate ratios for the number of sickness absence days per year and combining cohort-specific estimates with meta-analysis. The criteria for assessing the evidence included the strength of association, consistency across cohorts, robustness to adjustments and multiple testing, and impact assessment by use of population attributable fractions (PAF), with both internal lifestyle factor prevalence estimates and those obtained from European populations (PAF_external).

Findings

For 74 296 participants, during 446 478 person-years at risk, the most common diagnoses for sickness absence were musculoskeletal diseases (70·9 days per 10 person-years), depressive disorders (26·5 days per 10 person-years), and external causes (such as injuries and poisonings; 12·8 days per 10 person-years). Being overweight (rate ratio [adjusted for age, sex, socioeconomic status, and chronic disease at baseline] 1·30, 95% CI 1·21–1·40; PAF_external 8·9%) and low physical activity (1·23, 1·14–1·34; 7·8%) were associated with absences due to musculoskeletal diseases; heavy episodic drinking (1·90, 1·41–2·56; 15·2%), smoking (1·70, 1·42–2·03; 11·8%), low physical activity (1·67, 1·42–1·96; 19·8%), and obesity (1·38, 1·11–1·71; 5·6%) were associated with absences due to depressive disorders; heavy episodic drinking (1·64, 1·33–2·03; 11·3%), obesity (1·48, 1·27–1·72; 6·6%), smoking (1·35, 1·20–1·53; 6·3%), and being overweight (1·20, 1·08–1·33; 6·2%) were associated with absences due to external causes; obesity (1·82, 1·40–2·36; 11·0%) and smoking (1·60, 1·30–1·98; 10·3%) were associated with absences due to circulatory diseases; low physical activity (1·37, 1·25–1·49; 12·0%) and smoking (1·27, 1·16–1·40; 4·9%) were associated with absences due to respiratory diseases; and obesity (1·67, 1·34–2·07; 9·7%) was associated with absences due to digestive diseases.

Interpretation

Lifestyle factors are associated with sickness absence due to several diseases, but observational data cannot determine the nature of these associations. Future studies should investigate the cost-effectiveness of lifestyle interventions aimed at reducing sickness absence and the use of information on lifestyle for identifying groups at risk.

Funding

NordForsk, British Medical Research Council, Academy of Finland, Helsinki Institute of Life Sciences, and Economic and Social Research Council.

General Practitioners' recommendations of self-directed-exercises for musculoskeletal problems and perceived barriers and facilitators to doing so: a mixed methods study

BACKGROUND

Musculoskeletal problems substantially impact the demand for and the finances of the United Kingdom's National Health Service. Some of this demand and cost could be alleviated if patients use self-directed-exercises. The present study aims first to establish whether general practitioners already recommend self-directed-exercises and second to describe barriers and facilitators to making such recommendations.

METHOD

The design of the current study included surveys and interviews. The surveys were designed to draw out participants' tendency to recommend self-directed-exercises and their behavioral drivers to do so. The drivers investigated include 14 domains described by the Theoretical Domains Framework. The surveys were completed online and the responses were analyzed using descriptive reports and regression analyses. The interviews were designed to more fully understand participants' experiences recommending self-directed-exercises according to the same framework. The interviews were audio-taped, transcribed, and thematically analyzed.

RESULTS

The survey found that the following domains significantly predicted participants' tendency to recommend self-directed-exercises: Environmental contexts and resources, Goals, Intentions, Knowledge, Memory attention and decision processes, and Social/professional role. The interviews brought out four themes that could be leveraged to increase general practitioners' tendency to recommend self-directed-exercises: (1) Practitioners' beliefs about self-directed-exercises being effective, (2) Patients' motivations to engage in self-directed-exercises, (3) Time constraints, and (4) The ease with which practitioners can recommend self-directed-exercises.

CONCLUSIONS

Most general practitioners already recommend self-directed-exercises, though they note significant barriers that may prevent them from doing so. General practitioners' tendency to recommend self-directed-exercises would be bolstered by creating a respected central resource of exercise pamphlets. These pamphlets should clearly describe how different self-directed-exercises should be performed and evidence supporting their effectiveness.

Effectiveness and cost-effectiveness of neuromuscular exercise and back care counseling in female healthcare workers with recurrent non-specific low back pain: a blinded four-arm randomized controlled trial

Background

Registered healthcare workers worldwide have a high prevalence of work-related musculoskeletal disorders, particularly of the back. Multidisciplinary interventions among these workers have improved fear avoidance beliefs, but not low back pain (LBP) and related sickness absences, cost-effectiveness studies are scarce. Our purpose was to investigate the effectiveness and cost-effectiveness of three intervention-arms (combined neuromuscular exercise and back care counselling or either alone) compared with non-treatment.

Methods

We randomly assigned female healthcare workers with recurrent non-specific LBP to one of four study-arms: Combined neuromuscular exercise and back care counseling; Exercise; Counseling; and no intervention Control. We assessed the effectiveness of the interventions on intensity of LBP, pain interfering with work and fear avoidance beliefs against the Control, and calculated the incremental cost-effectiveness ratios for sickness absence and QALY.

Results

We conducted three sub-studies in consecutive years of 2011, 2012, and 2013 to reach an adequate sample size. All together 219 women were randomized within each sub-study, of whom 74 and 68% had adequate questionnaire data at 6 and 12 months, respectively. No adverse events occurred. Compliance rates varied between intervention-arms. After 12 months, the Combined-arm showed reduced intensity of LBP (p = 0.006; effect size 0.70, confidence interval 0.23 to 1.17) and pain interfering with work (p = 0.011) compared with the Control-arm. Work-related fear of pain was reduced in both the Combined- (p = 0.003) and Exercise-arm (p = 0.002). Physical activity-related fear was reduced only in the Exercise-arm (p = 0.008). During the study period (0–12 months) mean total costs were lowest in the Combined-arm (€476 vs. €1062–€1992, p < 0.001) as were the mean number of sickness absence days (0.15 vs. 2.29–4.17, p = 0.025). None of the intervention-arms was cost-effective for sickness absence. There was 85% probability of exercise-arm being cost-effective if willing to pay €3550 for QALY gained.

Conclusions

Exercise once a week for 6 months combined with five sessions of back care counseling after working hours in real-life settings effectively reduced the intensity of LBP, work interference due to LBP, and fear of pain, but was not cost-effective.

Trial registration

ClinicalTrials.gov, NCT01465698 November 7, 2011 (prospective).

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6293-9) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dose-response relationship of core-specific sensorimotor interventions in healthy, well-trained participants: study protocol for a (MiSpEx) randomized controlled trial

BACKGROUND

Core-specific sensorimotor exercises are proven to enhance neuromuscular activity of the trunk, improve athletic performance and prevent back pain. However, the dose-response relationship and, therefore, the dose required to improve trunk function is still under debate. The purpose of the present trial will be to compare four different intervention strategies of sensorimotor exercises that will result in improved trunk function.

METHODS/DESIGN

A single-blind, four-armed, randomized controlled trial with a 3-week (home-based) intervention phase and two measurement days pre and post intervention (M1/M2) is designed. Experimental procedures on both measurement days will include evaluation of maximum isokinetic and isometric trunk strength (extension/flexion, rotation) including perturbations, as well as neuromuscular trunk activity while performing strength testing. The primary outcome is trunk strength (peak torque). Neuromuscular activity (amplitude, latencies as a response to perturbation) serves as secondary outcome. The control group will perform a standardized exercise program of four sensorimotor exercises (three sets of 10 repetitions) in each of six training sessions (30 min duration) over 3 weeks. The intervention groups' programs differ in the number of exercises, sets per exercise and, therefore, overall training amount (group I: six sessions, three exercises, two sets; group II: six sessions, two exercises, two sets; group III: six sessions, one exercise, three sets). The intervention programs of groups I, II and III include additional perturbations for all exercises to increase both the difficulty and the efficacy of the exercises performed. Statistical analysis will be performed after examining the underlying assumptions for parametric and non-parametric testing.

DISCUSSION

The results of the study will be clinically relevant, not only for researchers but also for (sports) therapists, physicians, coaches, athletes and the general population who have the aim of improving trunk function.

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012917 . Registered on 22 August 2017.

A Decision Support System to Enhance Self-Management of Low Back Pain: Protocol for the selfBACK Project

BACKGROUND

Low back pain (LBP) is a leading cause of disability worldwide. Most patients with LBP encountered in primary care settings have nonspecific LBP, that is, pain with an unknown pathoanatomical cause. Self-management in the form of physical activity and strength and flexibility exercises along with patient education constitute the core components of the management of nonspecific LBP. However, the adherence to a self-management program is challenging for most patients, especially without feedback and reinforcement. Here we outline a protocol for the design and implementation of a decision support system (DSS), selfBACK, to be used by patients themselves to promote self-management of LBP.

OBJECTIVE

The main objective of the selfBACK project is to improve self-management of nonspecific LBP to prevent chronicity, recurrence and pain-related disability. This is achieved by utilizing computer technology to develop personalized self-management plans based on individual patient data.

METHODS

The decision support is conveyed to patients via a mobile phone app in the form of advice for self-management. Case-based reasoning (CBR), a technology that utilizes knowledge about previous cases along with data about the current patient case, is used to tailor the advice to the current patient, enabling a patient-centered intervention based on what has and has not been successful in previous patient cases. The data source for the CBR system comprises initial patient data collected by a Web-based questionnaire, weekly patient reports (eg, symptom progression), and a physical activity-detecting wristband. The effectiveness of the selfBACK DSS will be evaluated in a multinational, randomized controlled trial (RCT), targeting care-seeking patients with nonspecific LBP. A process evaluation will be carried out as an integral part of the RCT to document the implementation and patient experiences with selfBACK.

RESULTS

The selfBACK project was launched in January 2016 and will run until the end of 2020. The final version of the selfBACK DSS will be completed in 2018. The RCT will commence in February 2019 with pain-related disability at 3 months as the primary outcome. The trial results will be reported according to the CONSORT statement and the extended CONSORT-EHEALTH checklist. Exploitation of the results will be ongoing throughout the project period based on a business plan developed by the selfBACK consortium. Tailored digital support has been proposed as a promising approach to improve self-management of chronic disease. However, tailoring self-management advice according to the needs, motivation, symptoms, and progress of individual patients is a challenging task. Here we outline a protocol for the design and implementation of a stand-alone DSS based on the CBR technology with the potential to improve self-management of nonspecific LBP.

CONCLUSIONS

The selfBACK project will provide learning regarding the implementation and effectiveness of an app-based DSS for patients with nonspecific LBP.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/9379.

Muscle Strength and Neuromuscular Control in Low-Back Pain: Elite Athletes Versus General Population

The purpose of the study was to investigate the athletic-based specificity of muscle strength and neuromuscular control of spine stability in chronic non-specific low-back pain (LBP). Thirty elite athletes and 29 age-matched non-athletes with (15 athletes and 15 non-athletes) and without LBP (15 athletes and 14 non-athletes) participated in the study. Muscle strength was measured during maximal isometric trunk flexion and trunk extension contractions. The neuromuscular control of spine stability was analyzed by determining trunk stiffness, trunk damping, and onset times of the lumbar and thoracic erector spinae muscles after sudden perturbations (quick release experiments) as well as maximum Lyapunov exponents (local dynamic stability) using non-linear time series analysis of repetitive lifting movements. LBP was assessed using the visual analog scale. We found lower maximal trunk extension moments (p = 0.03), higher trunk damping (p = 0.018) and shorter onset times (p = 0.03) of the investigated trunk muscles in LBP patients in both athletes and non-athletes. Trunk stiffness and the local dynamic stability did not show any differences (p = 0.136 and p = 0.375, respectively) between LBP patients and healthy controls in both groups. It can be concluded that, despite the high-level of training in athletes, both athletes and non-athletes with LBP showed the same deconditioning of the lumbar extensor muscles and developed similar strategies to ensure spine stability after sudden perturbations to protect the spine from pain and damage. The findings highlight that specific training interventions for the trunk muscles are not only crucial for individuals of the general population, but also for well-trained athletes.

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.

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Effects of a Home-Based Telephone-Supported Physical Activity Program for Older Adult Veterans With Chronic Low Back Pain

BACKGROUND

Chronic low back pain (CLBP) is highly prevalent in older adults, leading to functional decline.

OBJECTIVE

The objective of this study was to evaluate physical activity (PA) only and PA plus cognitive-behavioral therapy for pain (CBT-P) among older adult veterans with CLBP.

DESIGN

This study was a pilot randomized trial comparing a 12-week telephone-supported PA-only intervention group (PA group) or PA plus CBT-P intervention group (PA + CBT-P group) and a wait-list control group (WL group).

SETTING

The study setting was the Durham Veterans Affairs Health Care System.

PARTICIPANTS

The study participants were 60 older adults with CLBP.

INTERVENTIONS

The PA intervention included stretching, strengthening, and aerobic activities; CBT-P covered activity pacing, relaxation techniques, and cognitive restructuring.

MEASUREMENTS

Feasibility measures included enrollment and completion metrics; acceptability was measured by completed phone calls. Primary outcomes included the Timed "Up & Go" Test and the PROMIS Health Assessment Questionnaire. Generalized linear mixed models were used to estimate changes within and between groups. Effect sizes were calculated with the Cohen d. Adverse effects were measured by self-report.

RESULTS

The mean participant age was 70.3 years; 53% were not white, and 93% were men. Eighty-three percent of participants completed the study, and the mean number of completed phone calls was 10 (of 13). Compared with the results for the WL group, small to medium treatment effects were found for the intervention groups in the Timed "Up & Go" Test (PA group: -2.94 [95% CI = -6.24 to 0.35], effect size = -0.28; PA + CBT-P group: -3.26 [95% CI = -6.69 to 0.18], effect size = -0.31) and the PROMIS Health Assessment Questionnaire (PA group: -6.11 [95% CI = -12.85 to 0.64], effect size = -0.64; PA + CBT-P group: -4.10 [95% CI = -11.69 to 3.48], effect size = -0.43). Small treatment effects favored PA over PA + CBT-P. No adverse effects were noted.

LIMITATIONS

This was a pilot study, and a larger study is needed to verify the results.

CONCLUSIONS

This pilot trial demonstrated that home-based telephone-supported PA interventions were feasible, acceptable, and safe for older adult veterans. The results provide support for a larger trial investigating these interventions.

Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain: a randomized-controlled trial

OBJECTIVES

This study aims to investigate the effect of physical therapy modalities on pain and functional status in patients with non-specific low back pain.

PATIENTS AND METHODS

Between February 2011 and August 2013, a total of 104 patients (38 males, 66 females; mean age 49.3±12.5 years; range 34 to 62 years) with non-specific chronic low back pain for more than 12 weeks without any neurological deficit were included in this randomized-controlled study. The patients were divided into two groups: physical therapy group (n=52) and control group (n=52). Both groups were given exercise and medical treatment; physiotherapy modalities were also applied in the physical therapy group. The patients were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Istanbul Low Back Pain Disability Index (ILBP) before treatment and at two weeks, three months, and one year after treatment.

RESULTS

A total of 100 patients completed one-year follow-up. In both groups, the VAS, ODI, and ILBP significantly improved after treatment (p<0.01), compared to before treatment values. There were statistically significant differences in the VAS, ODI, and ILBP scores at three months and one year after treatment between the physical therapy group and control group (p<0.05).

CONCLUSION

Multidisciplinary approaches including physical therapy should be implemented to provide long-term improvement in pain and functional status in the treatment of non-specific chronic low back pain.

Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report

Objective

The purpose of this case report was to describe the chiropractic management of thoracolumbar syndrome using multimodal therapies.

Clinical Features

A 33-year-old woman with 3 weeks of back pain presented to a chiropractic clinic. Nerve tension tests and local tenderness were present in a pattern described by Maigne, and she was diagnosed with thoracolumbar syndrome (Maigne syndrome) at her initial visit.

Intervention and Outcomes

The Oswestry Disability Index for low back pain (62%), STarT low back screen tool for clinical outcomes (6 points total, with a 2-point subscale), numeric pain rating scale (6/10 constant, 10/10 with provocation), and test-retest exercise audits were outcome measures. She received 3 treatment sessions, each with progressive exercise audits, and discharged with advice. At discharge, the patient scores substantially improved (Oswestry Disability Index: 8%, STarT: 1 point total, numeric pain rating scale: 1/10, 10% of the time), and she exhibited greater confidence in home care. Endurance tests were performed to establish baselines for future care, which included static back endurance test (timed 52 seconds) and side bridge endurance test (timed 43 seconds).

Conclusion

The patient responded positively to chiropractic care. After a short course of care, the patient reported reduced pain, alleviated symptoms, and improved physical function.

High prevalence of inadequate sitting and sleeping postures: a three-year prospective study of adolescents

There is a paucity of information regarding the development of body posture during adolescence. This three-year prospective study aimed to evaluate sitting and sleeping postures among adolescents, and to determine whether these postures are associated with age and sex. We assessed 525 adolescents aged 11-16 years from the fifth to eighth grades. These adolescents were reassessed three years later. The Back Pain and Body Posture Evaluation Instrument was used to evaluate the sleeping posture and three sitting positions: sitting to write, to use a computer, and during leisure activities. Our findings indicated a low prevalence of adequate sleeping and sitting postures at baseline, with a decrease in prevalence observed after three years for all postures. These changes were similar for both sexes. Moreover, we found a strong reduction of adequate posture prevalence for younger adolescents, but the oldest adolescents demonstrated no significant differences after three years. Early, rather than late, adolescence is a critical period for establishing inadequate sitting and sleeping postures. This has implications for posture throughout adulthood; hence, interventions targeted at this age group are needed.

Effectiveness of a standardised exercise programme for recurrent neck and low back pain: a multicentre, randomised, two-arm, parallel group trial across 34 fitness clubs in Finland

Background

Neck and low back pain (LBP) are common in office workers. Exercise trials to reduce neck and LBP conducted in sport sector are lacking. We investigated the effectiveness of the standardised Fustra20Neck&Back exercise program for reducing pain and increasing fitness in office workers with recurrent non-specific neck and/or LBP.

Method

Volunteers were recruited through newspaper and Facebook. The design is a multi-centre randomised, two-arm, parallel group trial across 34 fitness clubs in Finland. Eligibility was determined by structured telephone interview. Instructors were specially educated professionals. Neuromuscular exercise was individually guided twice weekly for 10 weeks. Webropol survey, and objective measurements of fitness, physical activity, and sedentary behavior were conducted at baseline, and at 3 and 12 months. Mean differences between study groups (Exercise vs Control) were analysed using a general linear mixed model according to the intention-to-treat principle.

Results

At least moderate intensity pain (≥40 mm) in both the neck and back was detected in 44% of participants at baseline. Exercise compliance was excellent: 92% participated 15−20 times out of 20 possible. Intensity and frequency of neck pain, and strain in neck/shoulders decreased significantly in the Exercise group compared with the Control group. No differences in LBP and strain were detected. Neck/shoulder and trunk flexibility improved, as did quality of life in terms of pain and physical functioning.

Conclusions

The Fustra20Neck&Back exercise program was effective for reducing neck/shoulder pain and strain, but not LBP. Evidence-based exercise programs of sports clubs have potential to prevent persistent, disabling musculoskeletal problems.

Are people with chronic low back pain meeting the physical activity guidelines? A co-twin control study

BACKGROUND

Despite a large amount of research investigating physical activity (PA) levels in people with chronic low back pain (LBP), no study has investigated whether people with chronic LBP are meeting the World Health Organization (WHO) PA guidelines. Furthermore, with genetics and the early shared environment substantially influencing the presence of LBP and PA engagement, these factors could confound the association between LBP and PA and need to be controlled for.

PURPOSE

This study aimed to investigate the association between chronic LBP and meeting the PA guidelines, while controlling for the effects of genetics and early shared environment.

DESIGN

This is a cross-sectional co-twin control study.

PATIENT SAMPLE

A cross-sectional analysis was performed on 1,588 twins from the Murcia Twin Registry in Spain with available data on LBP and PA from the 2013 data collection wave.

OUTCOME MEASURES

The exposure and outcome variables in our study were self-reported. Twins reporting a history of chronic LBP were asked follow-up questions to inform on the presence of recent LBP (within the past 4 weeks), previous LBP (no pain within the past 4 weeks), and persistent LBP (no pain-free month in the last 6 months). These were our exposure variables. Our outcome variable was meeting the WHO PA guidelines, which involved at least 75 minutes of vigorous-intensity PA, or at least 150 minutes of moderate-intensity PA per week.

METHODS

To investigate the association between chronic LBP and meeting the PA guidelines, we first performed a multivariate logistic regression on the total sample of twins. Co-variables entered the model if the univariate association between the co-variable, and both the exposure and the outcome reached a significance of p<.2. Second, to adjust for the influence of genetics and early shared environment, we performed a conditional multivariate logistic regression on complete twin pairs discordant for LBP. The Murcia Twin Registry is supported by Fundación Séneca, Regional Agency for Science and Technology, Murcia, Spain (08633/PHCS/08 and 15302/PHCS/10) and the Ministry of Science and Innovation, Spain (PSI11560-2009). Funding for this project has also been received from Fundación MAPFRE (2012). The authors declare that there are no conflicts of interest.

RESULTS

There was a significant inverse association between recent LBP and meeting the PA guidelines (odds ratio [OR]=0.71, p=.034). When controlling for genetics and early shared environment, this association disappeared. There was no association between previous (OR=0.95, p=.779) or persistent LBP (OR=0.78, p=.192) and meeting the PA guidelines.

CONCLUSION

Twins with recent LBP are less likely to meet the PA guidelines than those with no history of chronic LBP, highlighting the importance of incorporating PA promotion in the treatment of these individuals. Genetics and early shared environment appear to be confounding the association between LBP and PA, although this needs to be further tested in larger twin samples.

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.