How is recovery from low back pain measured? A systematic review of the literature

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Do Visual Pain Trajectories Reflect the Actual Course of Low Back Pain? A Longitudinal Cohort Study

Different trajectories of low back pain (LBP) have been identified prospectively using repeated measures. For these trajectories to inform clinical practice, they must be available in the clinical consultation. Therefore, identified LBP trajectories have been translated into visual pain trajectories (VPTs) that allow people with LBP, at the time of consult, to reflect upon their pain experience and identify the VPT that best categorizes their pain course. We have limited knowledge regarding the extent to which a chosen VPT reflects the prospectively experienced trajectory. Thus, we explored the distribution of pain intensity and pain pattern characteristics (from prospective pain trajectory data) within the retrospectively chosen VPT classes. We enrolled patients with LBP from Danish chiropractic practice. Using SMS, participants (n = 719) scored their pain weekly on an 11-point numerical rating scale for 52 weeks. At week 52, participants identified 1 of 8 VPTs that reflected their perceived back pain trajectory during the preceding year. We found that the chosen VPTs reflected pain intensity, but that pain patterns (episodic, fluctuating, and persistent) were not systematically recognized, and the experienced course varied substantially amongst participants within the same VPT. The VPTs are related to some aspects of the experienced LBP course but are not a proxy for the SMS-measured trajectories. Reasons for apparent mismatches between the experienced course of LBP and VPT recall warrant further investigation. PERSPECTIVE: Self-reported back pain trajectories reflected pain intensities obtained through weekly SMS tracking over a year, but participants' recall did not reflect the pain patterns (episodes and fluctuations) discovered prospectively. Clinicians can use self-reported pain trajectories to facilitate a dialog about pain experience, but not as a proxy for prospective measures.

Effectiveness of coordinated care to reduce the risk of prolonged disability among patients suffering from subacute or recurrent acute low back pain in primary care: protocol of the CO.LOMB cluster-randomized, controlled study

Background

Low back pain (LBP) is a common musculoskeletal condition and, globally, a leading cause of years lived with disability. It leads to reduced social participation, impaired quality of life, and direct and indirect costs due to work incapacity. A coordinated approach focusing on psychosocial risk factors, active reeducation, and the early use of tools to maintain employment, may be effective for improving prognosis of patients with LBP. Primary care professionals and multidisciplinary teams, who see patients in the early stages of LBP may be in the best position to implement such a coordinated approach. We designed this study to assess a coordinated multi-faceted strategy in primary care for patients with subacute or recurrent acute LBP.

Methods

The CO.LOMB study was designed as a multicentric, cluster-randomized, controlled study. Patients aged 18-60 years, with subacute or recurrent acute LBP are eligible. Patients also need to be employed (but can be on sick leave) with access to occupational health services. The clusters of GPs will be randomized (1:1) to either the Coordinated-care group or the Usual-care group. Patients will be assigned the group allocated to their GP. The healthcare professionals (GPs and associated physiotherapists) allocated to the Coordinated-care group will perform a 2-session study training. The following interventions are planned in the Coordinated-care group: exploration and management of psychosocial factors, active reeducation with a physiotherapist, the implementing of tools to maintain employment, and a reinforced cooperation between primary healthcare professionals. The primary objective is to assess the benefit of coordinated primary care to reduce disability in LBP patients at 12 months after enrollment: measure using the validated French version of the Roland Morris Disability Questionnaire. Secondary objectives include the evaluation of pain, work status, and quality of life at various time points. The study plans to enroll 500 patients in 20 GP clusters. Patients will be followed up for 12months.

Discussion

This study will evaluate the benefit of a coordinated multi-faceted strategy in primary care for patients with LBP. Notably whether this approach will alleviate the associated disability, attenuate pain, and promote the maintenance or return to work.

Clinical Trial Registration

NCT04826757.

"My Back is Fit for Movement": A Qualitative Study Alongside a Randomized Controlled Trial for Chronic Low Back Pain

A new wave of treatments has emerged to target nervous system alterations and maladaptive conceptualizations about pain for chronic low back pain. The acceptability of these treatments is still uncertain. We conducted a qualitative study alongside a randomized controlled trial to identify perceptions of facilitators or barriers to participation in a non-pharmacological intervention that resulted in clinically meaningful reductions across 12 months for disability compared to a sham intervention. We conducted semi-structured interviews with participants from the trial's active arm after they completed the 12-week program. We included a purposeful sample (baseline and clinical characteristics) (n = 20). We used reflexive thematic analysis informed by the Theoretical Framework of Acceptability for health care interventions. We identified positive and negative emotional/cognitive responses associated with treatment acceptability and potential efficacy, including emotional support, cognitive empowerment, readiness for self-management, and acceptance of face-to-face and online components designed to target the brain. These findings suggest the importance of psychoeducation and behavior change techniques to create a positive attitude towards movement and increase the perception of pain control; systematic approaches to monitor and target misconceptions about the interventions during treatment; and psychoeducation and behavior change techniques to maintain the improvements after the cessation of formal care. PERSPECTIVE: This article presents the experiences of people with chronic low back pain participating in a new non-pharmacological brain-targeted treatment that includes face-to-face and self-directed approaches. The facilitators and barriers of the interventions could potentially inform adaptations and optimization of treatments designed to target the brain to treat chronic low back pain.

Functional Tests Predicting Return to Work of Workers with Non-Specific Low Back Pain: Are There Any Validated and Usable Functional Tests for Occupational Health Services in Everyday Practice? A Systematic Review

The literature predominantly advocates subjective perception of disability and pain as an outcome measure for the functional evaluation of patients with low back pain (LBP). Physical outcome measurements are almost completely ignored. In this systematic review, we focused on physical functional measurements that can contribute to the prediction of patients' return to work (RTW) readiness after sick leave or rehabilitation. Searches were conducted in July 2022 without any time limit in the Cochrane Library, PEDro, PubMed and Scopus databases for functional and clinical tests reliable and applicable in clinical practice without demanding equipment. Two independent researchers extracted the data from the included articles in a standardised data collection form, and a third researcher validated the data extraction. No date restriction was applied. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in conducting the review. We found seven original articles, including six with an impact on predicting RTW. We found four fair and three poor original studies fulfilling our criteria. We found the Back Performance Scale (BPS) and back endurance test to be the most promising tests for occupational health service and the clinical practitioner. Radiation of back pain, with or without neurological deficiencies, had some predictive value in terms of RTW, too. The working conditions vary a lot, which causes inconsistency in the studies and in their interpretation. Functional tests could complete the widely used working ability evaluations methods such as the Work Ability Index (WAI) and are worth considering for future research. Overall, more research is needed in this field. The question of when LBP patients can resume everyday activities and work is not possible to determine with functional tests alone. Psychosocial aspects and work demands must be considered. PROSPERO: CRD42022353955. The study was funded by the University of Helsinki.

How is recovery defined and measured in patients with low back pain? Protocol for a mixed study systematic review

INTRODUCTION

This protocol describes the methods for a mixed study systematic review aiming to explore the definitions and measurements of recovery in patients with low back pain, and how perspectives of recovery differ between patients and providers. This review will be the first to review the concept of recovery in patients with low back pain across both quantitative and qualitative literature.

METHODS AND ANALYSIS

This protocol has been designed and reported in line with Preferred Reporting Items of Systematic Reviews and Meta-Analyses Protocols. The following databases will be electronically searched from database inception until 30 November 2021: Medline, EMBASE, CINAHL, Cochrane, PEDro. Grey literature will be searched for through targeted searching of ProQuest Dissertations and Theses and handsearching of the references of all included studies. Studies will be included if they include a patient population of >50% with low back pain (with or without leg pain), and mention the concept of recovery within the abstract, methods or results. The Mixed Methods Appraisal Tool will be used for quality assessment of both quantitative and qualitative included studies. Two independent reviewers will conduct the search, screen titles/abstracts and extract relevant data from full texts. Discrepancies between reviewers will be settled by a third reviewer with spinal pain expertise. For syntheses, thematic analysis will be used to analyse both qualitative and quantitative investigations to explore meanings, measurement and perspectives of recovery from a diverse evidence base. There is no clinical trial associated with this protocol.

ETHICS AND DISSEMINATION

There are no ethical issues associated with this systematic review, and ethics approval was not required. Once completed, the results of this review will be published in a peer-reviewed journal within the realm of spinal pain to help guide future research inquiries.

PROSPERO REGISTRATION NUMBER

CRD42022295804.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

The Patient-Reported Outcome Measures Used with Low Back Pain and the Attitude of Primary Healthcare Practitioners in Saudi Arabia toward Them

Background and objectives: The use of appropriate outcome measures can help guide multidimensional low back pain (LBP) management, elucidate the efficacy/effectiveness of interventions, and inform clinicians when selected targets have been achieved and this can be used for educational or research purposes. Aim: This study aimed to explore and describe the use, attitudes, knowledge, and beliefs regarding patient-reported outcome measures used by healthcare practitioners practising in Saudi Arabia who are frequently involved in the healthcare of individuals with LBP. Materials and Methods: A cross-sectional design was undertaken using a web-based survey. An electronic invitation to participate was sent to primary care physicians and physical therapists practising in Saudi Arabia. The survey included three sections: demographic data, a list of the most commonly used patient-reported outcome measures with LBP patients, and statements regarding attitudes, knowledge, and beliefs about outcome measures. Results: A total of 156 practitioners participated: 45 primary care physicians and 111 physical therapists. The numeric pain rating and visual analogue scales were the outcome measures most frequently reported as being often used by both primary care physicians and physical therapists. The majority of participants reported often using 1-2 patient reported outcome measures (PROMs). While most participants indicated that they were confident at selecting the most appropriate PROM, fewer were familiar with the concept of the minimally important clinical difference. A lack of Arabic versions of PROMs was reported as a barrier to using them to assess pain. Conclusions: This study shows that, although primary care physicians and physical therapists in Saudi Arabia frequently use patient-reported outcome measures in their clinical management of patients with LBP, there is a noticeable gap in the knowledge and use of the multidimensional outcome measures for LBP management among the participants. This highlights a need for professional training on the use of standardised outcome measures related to LBP.

Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study

ABSTRACT

Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

How Do Physical Therapists Measure Treatment Outcomes in Adults With Chronic Low Back Pain? A Systematic Review

BACKGROUND

There is an increasing recognition of the importance of using a conceptual framework covering the full range of relevant health domains and outcome measures addressed by physical therapy modalities in patients with chronic low back pain (CLBP). However, little is known about what outcome domains have been measured and through what measures in physical therapy research.

OBJECTIVE

The purpose of this review was to synthesize outcome domains, instruments, and cutoff values reported in published randomized controlled trials and their compliance with the original Patient-Reported Outcomes Measurement Information System (PROMIS) framework.

DATA SOURCES

Embase, MEDLINE, Cochrane Library, and Physiotherapy Evidence Database electronic databases were systematically searched from January 2008 to April 2019.

STUDY SELECTION

Randomized controlled trials that compared physical therapy with any other intervention for adults with CLBP were included.

DATA EXTRACTION

Study characteristics, outcome domains, instruments, and cutoff values were extracted by 2 reviewers. The PROMIS framework was used for domain categorization.

DATA SYNTHESIS

One hundred ninety-five studies were included, with 52 outcome domains and 45 cutoff values identified from 182 instruments reported. Only 14 of 195 studies assessed all PROMIS health core areas, whereas the PROMIS physical health core area was assessed in all included studies. Pain intensity and disability were the most frequently used domains.

LIMITATIONS

Only studies for which full texts were available in English were included.

CONCLUSIONS

This review identified a poor overlap between the PROMIS framework and outcome domains used to define the effectiveness of physical therapy in adults with CLBP. This finding suggests that other potential benefits resulting from physical therapy modalities are not being measured. Furthermore, a large diversity in the outcome domains and instruments was found.

The association between pain intensity and disability in patients with failed back surgery syndrome, treated with spinal cord stimulation

OBJECTIVE

Pain researchers demonstrated that pain intensity is not the most reliable measure of the success of chronic-pain treatment. Several research groups have proposed "core outcome domains", such as measurements of disability, to assess the effect of an intervention in pain patients. Up till now, studies investigating the relation between pain intensity and disability in patients treated with spinal cord stimulation (SCS) are lacking. Therefore, the current objective is to examine which pain-reporting strategy, routinely used in pain research, associates best with the degree of disability in these patients.

METHODS

Eighty-one failed back surgery syndrome patients (37 males and 44 females, mean age 54.6 years), treated with high-dose spinal cord stimulation (HD-SCS) are recruited. Pain intensity was scored on an 11-point numerical rating scale (NRS) for leg and back pain, while disability was assessed with the Oswestry disability index (ODI). The association between both variables was investigated with Spearman's correlation and Cramér's V.

RESULTS

Significant correlations (p < 0.001) are found between the absolute and relative differences of the ODI and NRS. Significant associations were found between reported cut-offs in literature (≤3, ≤5, and 50% pain relief) and the degree of disability. Finally, a significant association (p < 0.001) was found between the minimal clinical important difference.

CONCLUSIONS

In this study, we showed that the degree of disability was strongly associated with the pain intensity as measured using different methods. The standard method for reporting pain intensity reduction (50%) seems to associate the strongest with the degree of disability. However, a low degree of disability does not always reflect a low pain intensity.Implications for rehabilitationThe degree of disability reveals a good association with the reporting methods of pain intensity from the literature.The Oswestry disability index could serve as a valid tool to measure the effect of spinal cord stimulation on pain.Disability measures offer a better insight in the clinical profile of chronic pain patients than a pain intensity score.

Which patients do not seek additional medical care after a self-management class for low back pain? An observational cohort

OBJECTIVES

(1) To identify baseline variables associated with patients that sought no additional care during the 12 months following a single self-management education session for low back pain (LBP), and (2) in those who sought care, to determine whether the same variables were associated with low versus high downstream LBP-related healthcare utilization.

DESIGN

An observational cohort.

SETTING

Single large military hospital.

PARTICIPANTS

A total of 733 patients with LBP.

INTERVENTION

Single self-management education session.

MAIN OUTCOMES

Eleven variables were explored in two distinct logistic regression models: (1) no additional care versus additional care, and (2) low versus high number of additional visits in the additional care group.

RESULTS

In the first model, not being on active duty service (odds ratio (OR) = 1.98, 95% confidence interval (CI) = 1.37-2.86), low baseline disability (OR = 1.02, 95% CI = 1.00-1.04), low baseline fear-avoidance related to work (OR = 1.02, 95% CI = 1.00-1.03), and, in the last year, no opioid prescriptions (OR = 1.44, 95% CI = 1.00-2.07), physical therapy (OR = 1.63, 95% CI = 1.00-2.65), or sleep disorder diagnosis (OR = 1.62, 95% CI = 1.05-2.51) significantly increased the odds that patients would not seek any additional care. In the second model, not being on active duty service (OR = 2.18, 95% CI = 1.38-3.46), low baseline disability (OR = 1.04, 95% CI = 1.02-1.06), and no opioid prescriptions in the prior year (OR = 2.19, 95% CI = 1.42-3.37) increased the odds that patients would have less visits (⩽2 visits).

CONCLUSION

Our study found several variables that helped determine whether patients would seek little or no additional care during the 12 months following a self-management education class for LBP.

Do prognostic variables predict a set of outcomes for patients with chronic low back pain: a long-term follow-up secondary analysis of a randomized control trial

Objective: The objective was to explore for universal prognostic variables, or predictors, across three different outcome measures in patients with chronic low back pain (LBP). We hypothesized that selected prognostic variables would be 'universal' prognostic variables, regardless of the outcome measures used. Methods: This study was a secondary analysis of data from a previous randomized controlled trial comparing the McKenzie treatment approach with placebo in patients with chronic LBP. Ten baseline prognostic variables were explored in predictive models for three outcomes: pain intensity, disability, and global perceived effect, at 6 and 12 months. Predictive models were created using backward stepwise logistic and linear multivariate regression analyses. Results: Several predictors were present including age, expectancy of improvement, global perceived effect; however, we only identified baseline disability as a universal predictor of outcomes at 6 months. The second most represented universal predictor was baseline pain intensity for outcomes at 12 months. Discussion: Only two predictors demonstrated an association with more than one outcome measure. High baseline disability predicts multidimensional outcome measures at 6 months in patients with chronic LBP while baseline pain intensity can best predict the outcome at 12 months. Nevertheless, other predictors seem to be unique to the outcome used. Level of evidence: 2c.

Improvement in Work Ability, Psychological Distress and Pain Sites in Relation to Low Back Pain Prognosis: A Longitudinal Observational Study in Primary Care

STUDY DESIGN

Prospective observational study pooled from two clinical cohorts.

OBJECTIVE

To investigate the longitudinal relation between multisite pain, psychological distress, and work ability with disability, pain, and quality of life.

SUMMARY OF BACKGROUND DATA

Knowledge of prognostic factors is essential for better management of patients with low back pain (LBP). All domains of the biopsychosocial model have shown prognostic value; however, clinical studies rarely incorporate all domains when studying treatment outcome for patients with LBP.

METHODS

A total of 165 patients with nonspecific LBP seeking primary care physiotherapy were included. Mixed-effects models were used to estimate longitudinal relations between the exposure variables and concurrent measures of outcomes at baseline and 3 months. Logistic regression was used to estimate odds ratios for minimal important difference in outcome.

RESULTS

Higher work ability was associated with less disability -2.6 (95% confidence interval [CI]: -3.3, -2.0), less pain: -0.4 (95% CI: -0.5, -0.3), and higher quality of life 0.03 (95% CI: 0.02, 0.04). Higher psychological distress and number of pain sites were associated with higher disability: 10.9 (95% CI: 7.7, 14.1) and 2.3 (95% CI: 1.4, 3.2) higher pain: 1.9 (95% CI: 1.3, 2.5) and 0.4 (95% CI: 0.2, 0.5), and lower quality of life: -0.1 (95% CI: -0.2, -0.1) and -0.02 (95% CI: -0.03, -0.01), respectively. Improvement in work ability showed consistent associations with successful outcome for disability (odds ratio [OR]: 4.8, 95% CI: 1.3, 18.1), pain (OR: 3.6, 95% CI: 1.1, 12.1), and quality of life (OR: 4.5, 95% CI: 1.4, 15.1) at 3 months. Reduced psychological distress was associated with improvement in pain only (OR 4.0, 95% CI: 1.3, 12.3).

CONCLUSION

More pain sites, higher psychological distress, or lower work ability showed higher disability, more pain, and lower quality of life in patients with LBP. Only improvement in work ability was consistently related to successful outcomes.

LEVEL OF EVIDENCE

2.

Contrasting real time quantitative measures (weekly SMS) to patients' retrospective appraisal of their one-year's course of low back pain; a probing mixed-methods study

Background

Due to the recurrent nature of low back pain (LBP), the traditional concepts of cure and recovery are challenged, and investigating the course rather than status at fixed time-points may help us understand prognosis as well as treatment effect. However, methods of frequent measuring still need development and validation. Therefore, this study aims to evaluate the agreement between continuous, quantitative self-assessment (weekly SMS) of the course of LBP over a one-year period and qualitatively derived retrospective patient self-appraisal of the same time-period.

Methods

Participants were 32 subjects with LBP from primary care. The quantitative measures consisted of weekly SMS questions for one-year about pain intensity, days with LBP, and activity limitations for that week. For each subject, the weekly responses were graphed and categorized into categories based on intensity, variation and overall change patterns. Qualitative measures were based on semi-structured telephone interviews one-year after a consultation for LBP, where two coders independently categorized the self-appraisal of LBP course into the same predefined categories as the SMS-based trajectories. Furthermore, patients' perceived overall recovery was related to variation patterns from SMS track.

Results

There was perfect agreement for 48% in the pain intensity domain, 53% in the variation domain and 63% in the change pattern domain. Most of the discordant cases were classified in neighboring categories with the majority relating to fluctuating patterns. The self-perceived overall recovery status seemed to be reflected quite well by the quantitative measures of pain intensity and days with pain in this study.

Conclusion

This study shows that a real time quantitative measure (weekly SMS) and the patient's retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient's ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.

From acute to persistent low back pain: a longitudinal investigation of somatosensory changes using quantitative sensory testing-an exploratory study

Introduction

Chronic low back pain (LBP) is commonly associated with generalised pain hypersensitivity. It is suggested that such somatosensory alterations are important determinants for the transition to persistent pain from an acute episode of LBP. Although cross-sectional research investigating somatosensory function in the acute stage is developing, no longitudinal studies designed to evaluate temporal changes have been published.

Objectives

This exploratory study aimed to investigate the temporal development of somatosensory changes from the acute stage of LBP to up to 4 months from onset.

Methods

Twenty-five people with acute LBP (<3 weeks' duration) and 48 pain-free controls were prospectively assessed at baseline using quantitative sensory testing with the assessor blinded to group allocation, and again at 2 and 4 months. Psychological variables were concurrently assessed. People with acute LBP were classified based on their average pain severity over the previous week at 4 months as recovered (≤1/10 numeric rating scale) or persistent (≥2/10 numeric rating scale) LBP.

Results

In the persistent LBP group, (1) there was a significant decrease in pressure pain threshold between 2 and 4 months (P < 0.013), and at 4 months, pressure pain threshold was significantly different from the recovered LBP group (P < 0.001); (2) a trend towards increased temporal summation was found at 2 months and 4 months, at which point it exceeded 2 SDs beyond the pain-free control reference value. Pain-related psychological variables were significantly higher in those with persistent LBP compared with the recovered LBP group at all time points (P < 0.05).

Conclusion

Changes in mechanical pain sensitivity occurring in the subacute stage warrant further longitudinal evaluation to better understand the role of somatosensory changes in the development of persistent LBP. Pain-related cognitions at baseline distinguished persistent from the recovered LBP groups, emphasizing the importance of concurrent evaluation of psychological contributors in acute LBP.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial

BACKGROUND

The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care.

OBJECTIVES

To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective.

DESIGN

The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation.

SETTING

Five NHS acute trusts in England.

PARTICIPANTS

Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone.

INTERVENTIONS

All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session.

MAIN OUTCOME MEASURES

Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months.

RESULTS

Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84.

LIMITATIONS

Poor recruitment was a limiting factor.

CONCLUSIONS

This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain.

FUTURE WORK

Further work is needed to test recruitment from alternative clinical situations.

TRIAL REGISTRATION

EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: A systematic review

Background

Almost 80% of people have low back pain at least once in their life. Clinical guidelines emphasize the use of conservative physiotherapy and the importance of staying active. While the psychological factors predicting poor recovery following surgical intervention are understood, the psychosocial factors associated with poor outcomes following physiotherapy have yet to be identified.

Methods

Electronic searches of PubMed, Medline, CINAHL, PsycINFO and EBSCO were conducted using terms relating to psychosocial factors, chronic low back pain, disability and physiotherapy. Papers examining the relationship between psychosocial factors and pain and disability outcomes following physiotherapy were included. Two reviewers selected, appraised and extracted studies independently.

Results

In total, 10 observational studies were identified that suggested an association between fear of movement, depression, self-efficacy and catastrophizing in modifying pain and disability outcomes following physiotherapy.

Discussion

Although limited by methodological shortcomings of included studies, and heterogeneity of physiotherapy interventions and measures of disability and psychosocial outcomes, the findings are consistent with other research in the context of back pain and physiotherapy, which suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist. However, a direct relationship cannot be concluded from this study.

Conclusion

Findings suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist, which warrants further study.

An Observational Study on Recurrences of Low Back Pain During the First 12 Months After Chiropractic Treatment

OBJECTIVES

The purpose of this study was to investigate recurrence rate and prognostic factors in a large population of patients with low back pain (LBP) up to 1 year after chiropractic care using standardized definitions.

METHODS

In Switzerland, 722 patients with LBP (375 male; mean age = 44.5 ± 13.8 years) completed the Numeric Rating Scale for pain (NRS) and the Oswestry Disability Index (ODI) before treatment and 1, 3, 6, and 12 months later (ODI up to 3 months). Based on NRS values, patients were categorized as "fast recovery," "slow recovery," "recurrent," "chronic," and "others." In multivariable logistic regression models, age, sex, work status, duration of complaint (subacute: ≥14 days to <3 months; chronic: ≥3 months), previous episodes, baseline NRS, and baseline ODI were investigated as predictors.

RESULTS

Based on NRS values, 13.4% of the patients were categorized as recurrent. The recurrent pattern significantly differed from fast recovery in duration of complaint (subacute: odds ratio [OR] = 3.3; chronic: OR = 10.1). The recurrent and chronic pattern significantly differed in duration of complaint (chronic: OR = 0.14) and baseline NRS (OR = 0.75).

CONCLUSION

Recurrence rate was low in this LBP patient population. The duration of complaint before treatment was the main predictor for recurrence. The fact that even subacute duration significantly increased the odds for an unfavorable course of LBP is of clinical relevance.

Considerations in physical therapy management of a non-responding patient with low back pain

STUDY DESIGN

Case Study.

BACKGROUND AND PURPOSE

Low back pain is a common condition managed by physical therapists (PT). Screening tools have been developed to assist the PT with medical screening of patients for serious disease. Sinister pathologies may present as musculoskeletal symptoms during the patient examination. It is important for the PT to frequently reevaluate their patient's response to therapeutic interventions and refer for further evaluation if they are not responding to conservative care.

CASE DESCRIPTION

This case reports on the history and examination findings of a 36-year-old male presenting with recurrent low back pain. An emphasis is placed on the therapist's understanding and use of screening tools when interviewing patients and determining when medical referral may be indicated based on the patients history and examination findings. A review of the evidence on the diagnostic accuracy of screening strategies for malignancy in patients presenting with low back pain is presented.

CONCLUSION

Sinister causes for low back pain are extremely rare. It is important that PTs be familiar with specific signs and symptoms that may indicate serious pathology when evaluating patients with low back pain. Identification of two red flags from this patient's history leads the clinician to refer the patient back to their primary care provider (PCP) for further investigation. They included: 1) the patient's inability to improve after one month and 2) clinicians' judgment. Use of "clinical judgment" may assist the PT in determining if their patient needs further investigation.

Predictors for global perceived effect after physiotherapy in patients with neck pain: an observational study

OBJECTIVE

To investigate the prognostic importance of a number of sensorimotor and psychological factors for global perceived effect (GPE) after physiotherapy in patients with neck pain. In addition to baseline values, change scores were used as independent variables to identify treatment-modifiable factors.

DESIGN

Clinical cohort study.

SETTING

Primary and secondary healthcare physiotherapy clinics.

PARTICIPANTS

Patients (n=70) with non-specific neck pain.

INTERVENTION

Usual care physiotherapy.

METHODS

A three-dimensional motion tracking system was used to measure neck motion and sensorimotor variables, in addition to self-reported outcomes covering personal, somatic and psychological factors at baseline (before treatment) and at 2 months. Logistic regression was used to analyse associations between the prognostic variables and the primary outcome (GPE) at 2 months.

RESULTS

At baseline, neck motion and motor control, pain duration and functioning were the strongest predictors for GPE, with no effect of psychological factors. Among the change variables, reduced pain intensity [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.31 to 2.62], increased functioning (OR 1.46; 95% CI 1.11 to 1.92), reduced disability (OR 1.12; 95% CI 1.05 to 1.20), reduced kinesiophobia (OR 1.21; 95% CI 1.07 to 1.37), reduced catastrophising (OR 1.09; 95% CI 1.09 to 1.18) and increased self-efficacy (OR 1.12; 95% CI 1.03 to 1.21) were significantly associated with GPE.

CONCLUSIONS

Both baseline values and change in pain intensity and functioning predicted GPE at 2 months. Psychological factors such as kinesiophobia, catastrophising and self-efficacy were only able to predict outcome by their change scores, indicating that these factors are modifiable by common physiotherapy practice and are important for GPE.

Predicting recovery in patients with acute low back pain: A Clinical Prediction Model

BACKGROUND

There is substantial variability in the prognosis of acute low back pain (LBP). The ability to identify the probability of individual patients recovering by key time points would be valuable in making informed decisions about the amount and type of treatment to provide. Predicting recovery based on presentation 1-week after initially seeking care is clinically important and may be more accurate than predictions made at initial presentation. The aim of this study was to predict the probability of recovery at 1-week, 1-month and 3-months after 1-week review in patients who still have LBP 1-week after initially seeking care.

METHODS

The study sample comprised 1070 patients with acute LBP, with a pain score of ≥2 1-week after initially seeking care. The primary outcome measure was days to recovery from pain. Ten potential prognostic factors were considered for inclusion in a multivariable Cox regression model.

RESULTS

The final model included duration of current episode, number of previous episodes, depressive symptoms, intensity of pain at 1-week, and change in pain over the first week after seeking care. Depending on values of the predictor variables, the probability of recovery at 1-week, 1-month and 3-months after 1-week review ranged from 4% to 59%, 19% to 91% and 30% to 97%, respectively. The model had good discrimination (C = 0.758) and calibration.

CONCLUSIONS

This study found that a model based on five easily collected variables could predict the probability of recovery at key time points in people who still have LBP 1-week after seeking care.

SIGNIFICANCE

A clinical prediction model based on five easily collected variables was able to predict the likelihood of recovery from an episode of acute LBP at three key time points. The model had good discrimination (C = 0.758) and calibration.

Tutorial for writing systematic reviews for the Brazilian Journal of Physical Therapy (BJPT)

Systematic reviews aim to summarize all evidence using very rigorous methods in order to address a specific research question with less bias as possible. Systematic reviews are widely used in the field of physical therapy, however not all reviews have good quality. This tutorial aims to guide authors of the Brazilian Journal of Physical Therapy on how systematic reviews should be conducted and reported in order to be accepted for publication. It is expected that this tutorial will help authors of systematic reviews as well as journal editors and reviewers on how to conduct, report, critically appraise and interpret this type of study design.

Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio [OR] = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial.

PERSPECTIVE

This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.

Classification of patients with incident non-specific low back pain: implications for research

BACKGROUND CONTEXT

Comparing research studies of low back pain is difficult because of heterogeneity. There is no consensus among researchers on inclusion criteria or the definition of an episode.

PURPOSE

This study aimed to determine pattern(s) of recurrent non-specific low back pain from data collected over 27 months.

STUDY DESIGN/SETTING

This study used retrospective cohort study using administrative claims from multiple payers. Although claims are designed for capturing costs, not clinical complexity, they are valid for describing utilization patterns, which are not affected by potential "upcoding."

PATIENT SAMPLE

The patient sample consisted of population-based, nationally generalizable sample of 65,790 adults with continuous medical and pharmaceutical commercial health insurance who received health care for incident, non-specific low back pain. Potential subjects were excluded for plausible cause of the pain, severe mental illness, or cognitive impairment.

OUTCOME MEASURES

Diagnostic and therapeutic health-care services, including medical, surgical, pharmaceutical, and complementary, received in inpatient, outpatient, and emergency settings were the outcome measures for this study.

METHODS

The methods used for this study were latent class analysis of health-care utilization over 27 months (9 quarters) following index diagnosis of non-specific low back pain occurring in January-March 2009 and an analysis sample with 60% of subjects (n=39,597) and validation sample of 40% (n=26,193).

RESULTS

Four distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over 6 months, but maintain a 37-48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65-78% and 84-90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6-99.3%). Grouping was not related to demographic or clinical characteristics.

CONCLUSIONS

The four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A 6-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints.

Recovery From Chronic Low Back Pain After Osteopathic Manipulative Treatment: A Randomized Controlled Trial

Context: Little is known about recovery after spinal manipulation in patients with low back pain (LBP).

Objective: To assess recovery from chronic LBP after a short regimen of osteopathic manipulative treatment (OMT) in a responder analysis of the OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial.

Methods: A randomized double-blind, sham-controlled trial was conducted to determine the efficacy of 6 OMT sessions over 8 weeks. Recovery was assessed at week 12 using a composite measure of pain recovery (10 mm or less on a 100-mm visual analog scale) and functional recovery (2 or less on the Roland-Morris Disability Questionnaire for back-specific functioning). The RRs and numbers-needed-to-treat (NNTs) for recovery with OMT were measured, and corresponding cumulative distribution functions were plotted according to baseline LBP intensity and back-specific functioning. Multiple logistic regression was used to compute the OR for recovery with OMT while simultaneously controlling for potential confounders. Sensitivity analyses were performed to corroborate the primary results.

Results: There were 345 patients who met neither of the recovery criteria at baseline in the primary analyses and 433 patients who met neither or only 1 of these criteria in the sensitivity analyses. There was a large treatment effect for recovery with OMT (RR, 2.36; 95% CI, 1.31-4.24; P=.003), which was associated with a clinically relevant NNT (8.9; 95% CI, 5.4-25.5). This significant finding persisted after adjustment for potential confounders (OR, 2.92; 95% CI, 1.43-5.97; P=.003). There was also a significant interaction effect between OMT and comorbid depression (P=.02), indicating that patients without depression were more likely to recover from chronic LBP with OMT (RR, 3.21; 95% CI, 1.59-6.50; P<.001) (NNT, 6.5; 95% CI, 4.2-14.5). The cumulative distribution functions demonstrated optimal RR and NNT responses in patients with moderate to severe levels of LBP intensity and back-specific dysfunction at baseline. Similar results were observed in the sensitivity analyses.

Conclusions: The OMT regimen was associated with significant and clinically relevant measures for recovery from chronic LBP. A trial of OMT may be useful before progressing to other more costly or invasive interventions in the medical management of patients with chronic LBP. (ClinicalTrials.gov number NCT00315120)

Absence of low back pain to demarcate an episode: a prospective multicentre study in primary care

Background

It has been proposed that an episode of low back pain (LBP) be defined as: “a period of pain in the lower back lasting for more than 24 h preceded and followed by a period of at least 1 month without LBP”. Previous studies have tested the definition in the general population and in secondary care populations with distinctly different results. The objectives of this study (in a primary care population) were to investigate the prevalence of 1) the number of consecutive weeks free from bothersome LBP, 2) the prevalence of at least four consecutive weeks free from bothersome LBP at any time during the study period, and 3) the prevalence of at least four consecutive weeks free from bothersome LBP at any time during the study period among subgroups that reported >30 days or ≤30 days of LBP the preceding year.

Method

In this prospective multicentre study subjects with LBP (n = 262) were consecutively recruited from chiropractic primary care clinics in Sweden. The number of days with bothersome LBP was collected through weekly automated text messages. The maximum number of weeks in a row without bothersome LBP and the number of periods of at least four consecutive weeks free from bothersome LBP was counted for each individual and analysed as proportions.

Results

Data from 222 recruited subjects were analysed, of which 59 % reported at least one period of four consecutive weeks free from bothersome LBP. The number of consecutive pain free weeks ranged from 82 (at least one) to 31 % (9 or more). In subjects with a total duration of LBP of ≤ 30 days the previous year, 75 % reported a period of 4 consecutive weeks free from bothersome LBP during the study period whereas this was reported by only 48 % of subjects with a total duration of LBP of >30 days the previous year.

Conclusion

Prevalence of four consecutive pain free weeks is found in the majority of subjects in this population logically reflects duration of LBP within the sample and may be applied on patients in primary care to demarcate a LBP episode.

Yoga as a treatment for chronic low back pain: A systematic review of the literature

OBJECTIVES

Chronic low back pain (CLBP) affects millions of people worldwide, and appears to be increasing in prevalence. It is associated not only with pain, but also with increased disability, psychological symptoms, and reduced quality of life. There are various treatment options for CLBP, but no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as a CLBP treatment approach. The objective of this paper is to review the current literature supporting the efficacy of yoga for CLBP.

METHODS

A literature search through the beginning of 2015 was conducted in Pub Med for randomized control trials addressing treatment of CLBP with yoga.

RESULTS

In this review we evaluate the use of yoga as a treatment for CLBP. Specifically we evaluate how yoga impacts physical functioning and disability, pain, and associated psychological symptoms. We also evaluate possible mediators of the effect of yoga and the safety of yoga.

DISCUSSION

With few exceptions, previous studies and the recent randomized control trials (RCTs) indicate that yoga can reduce pain and disability, can be practiced safely, and is well received by participants. Some studies also indicate that yoga may improve psychological symptoms, but these effects are currently not as well established.

Primary outcome measure use in back pain trials may need radical reassessment

Background

The answers to patient reported outcome measures and global transition questions for back pain can be discordant. For example, the most commonly used outcome measure in back pain trials, the Roland Morris Disability Questionnaire (RMDQ), can show improvement even though participants say that their back pain is worse. This gives cause for concern as transition questions are used as anchors to estimate minimally important change (MIC) thresholds on patient reported outcome measures such as the RMDQ. We aimed to explore and compare what people with back pain think when they respond to a transition question and when they complete the RMDQ.

Methods

We purposively sampled people enrolled on a back pain randomised controlled trial who completed the RMDQ and two transition questions. One enquired about change in ability to perform tasks, the other about change in back pain. We sampled participants with discordance (in both directions), and participants with concordant scores. We explored participants’ thought processes using in-depth interviews.

Results

We completed 35 in-depth interviews. People with discordant RMDQ change and transition question responses attend to different factors when responding to transition questions compared to people with concordant scores. In particular, those for whom the RMDQ change indicated greater improvement than transition questions, prioritised their pain ahead of functional disability. When completing the RMDQ, participants’ thought processes were comparatively more objective, and specific to each statement.

Conclusion

Approaches to primary outcome assessment in back pain needs re-assessment. The RMDQ may be unsuitable for use as a primary outcome measure since patients may not attend to thinking about their back pain when completing it: patients’ abilities to cope with tasks can be independent of the change in their back pain. Some participants who improve on the RMDQ consider themselves globally worse. As transition questions can be driven by pain and other physical factors, transition questions should not be used to anchor minimally important change thresholds on the RMDQ.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0534-1) contains supplementary material, which is available to authorized users.

Psychological predictors of recovery from low back pain: a prospective study

Background

Recovery from low back pain (LBP) is an important outcome for patients and clinicians. Psychological factors are known to impact the course of LBP but have not been extensively investigated for predicting recovery. The purposes of this study were to: 1) describe LBP recovery rates at 6 months following 4 weeks of physical therapy; 2) identify psychological factors predictive of 6 month recovery status; and 3) identify psychological factors that co-occur with 6 month recovery status.

Methods

This study was a secondary analysis of a prospective cohort of patients (n = 111) receiving outpatient physical therapy for LBP. Patients were administered the STarT Back Screening Tool (SBT), individual psychological measures, a numerical pain rating scale (NPRS) and Roland Morris Disability Questionnaire (RMDQ) at intake, 4-week, and 6-month assessments. LBP recovery was operationally defined based on meeting NPRS = 0/10 and RMDQ ≤ 2 criterion at 6-month follow-up assessment. Recovery groups were then compared for differences on all variables at intake and on individual psychological measures at 6-months. Discriminant function analysis (DFA) identified which descriptive variables were predictive of recovery status.

Results

The 6-month recovery rate was 14/111 (12.6%) for the combined NPRS and RMDQ criterion. Non-recovered patients were associated with SBT risk status (p = 0.004), higher intake pain intensity (p = .008) and higher depressive symptoms (p < .001) scores compared to recovered patients. The overall accuracy for intake classification using DFA was 87.2% with SBT risk status, pain intensity, and depressive symptoms all making unique contributions. At 6-months, non-recovered patients had higher fear-avoidance, kinesiophobia, and depressive symptoms (p’s < .001) compared to recovered patients. The overall accuracy for 6-month classification using DFA was 86.4% with fear-avoidance, kinesiophobia, and depressive symptoms all making unique contributions.

Conclusions

Our findings indicated that psychological risk status, depressive symptoms, and pain intensity were predictive of 6 month recovery status. Furthermore elevated fear-avoidance, kinesiophobia, and depressive symptoms co-occurred with non-recovery at 6 months. Future studies should investigate whether stratified psychologically informed treatment options have the potential to improve recovery rates for those most at risk for non-recovery.

Prognosis and course of pain in patients with chronic non-specific low back pain: A 1-year follow-up cohort study

BACKGROUND

It remains unclear to what extent patients recover from chronic non-specific low back pain (NSLBP). The objective of this study was to determine (1) the course of chronic NSLBP in tertiary care and (2) which factors predicted 5- and 12-month outcomes.

METHODS

This prospective study includes 1760 chronic NSLBP patients from a rehabilitation clinic (mean age 40.1 years, SD 10.6). After baseline measurement, patients followed a 2-month multidisciplinary therapy programme; evaluation took place at 2, 5 and 12 months post baseline. Recovery was defined as (1) relative recovery [30% improvement on the pain, visual analogue scale (VAS) compared with baseline] and (2) absolute recovery (VAS pain ≤ 10 mm). The multivariate logistic regression analysis included 23 baseline characteristics.

RESULTS

Patient-reported intensity of back pain decreased from 55.5 (SD 23.0) at baseline to 37.0 (SD 23.8), 35.3 (SD 26.1) and 32.3 (SD 26.9) at 2-, 5- and 12-month follow-up, respectively. Younger age, back pain at baseline, no psychological/physical dysfunction (Symptom Check List-90, item 9), and higher baseline scores on the physical component scale and mental component scale of quality of life (Short Form-36) were positively associated with recovery at 5 and 12 months. At 5-month follow-up, higher work participation at baseline was also a prognostic factor for both definitions of recovery. At 12-month follow-up, having co-morbidity was predictive for both definitions.

CONCLUSION

The results of this study indicate that in chronic NSLBP patients, bio-psychosocial prognostic factors may be important for clinicians when predicting recovery in back pain intensity during a 1-year period.

Defining recovery in chronic fatigue syndrome: a critical review

PURPOSE

In chronic fatigue syndrome (CFS), the lack of consensus on how recovery should be defined or interpreted has generated controversy and confusion. The purpose of this paper was to systematically review, compare, and evaluate the definitions of recovery reported in the CFS literature and to make recommendations about the scope of recovery assessments.

METHODS

A search was done using the MEDLINE, PubMed, PsycINFO, CINAHL, and Cochrane databases for peer review papers that contained the search terms "chronic fatigue syndrome" and "recovery," "reversal," "remission," and/or "treatment response."

RESULTS

From the 22 extracted studies, recovery was operationally defined by reference with one or more of these domains: (1) pre-morbid functioning; (2) both fatigue and function; (3) fatigue (or related symptoms) alone; (4) function alone; and/or (5) brief global assessment. Almost all of the studies measuring recovery in CFS did so differently. The brief global assessment was the most common outcome measure used to define recovery. Estimates of recovery ranged from 0 to 66 % in intervention studies and 2.6 to 62 % in naturalistic studies.

CONCLUSIONS

Given that the term "recovery" was often based on limited assessments and less than full restoration of health, other more precise and accurate labels (e.g., clinically significant improvement) may be more appropriate and informative. In keeping with common understandings of the term recovery, we recommend a consistent definition that captures a broad-based return to health with assessments of both fatigue and function as well as the patient's perceptions of his/her recovery status.

Depression impacts the course of recovery in patients with acute low-back pain

Little is known about the course of recovery of acute low back pain (LBP) patients as a function of depression. In a prospective study, 286 acute LBP patients were assessed at baseline and followed up over 6 months. Recovery was defined as improvement in the Oswestry Disability Index (ODI). Repeated-measures analysis of covariance was employed with ODI as repeated factor, age, sex, and body mass index as covariates, depression and all other potential prognostic factors as between-subject factors. Of study participants, 18% were classified as depressive (>33 points on the Zung Self-Rating Depression Scale). Of 286 participants, 135 were lost to follow-up. In the longitudinal sample of 151 patients the course of recovery was slower in depressive patients. Depression was associated with LBP especially after 6 weeks and should therefore be included in screening instruments for acute LBP patients to identify those at risk of delayed recovery at an early stage.

Recovery from chronic fatigue syndrome after treatments given in the PACE trial

BACKGROUND

A multi-centre, four-arm trial (the PACE trial) found that rehabilitative cognitive behaviour therapy (CBT) and graded exercise therapy (GET) were more effective treatments for chronic fatigue syndrome (CFS) than specialist medical care (SMC) alone, when each was added to SMC, and more effective than adaptive pacing therapy (APT) when added to SMC. In this study we compared how many participants recovered after each treatment.

METHOD

We defined recovery operationally using multiple criteria, and compared the proportions of participants meeting each individual criterion along with two composite criteria, defined as (a) recovery in the context of the trial and (b) clinical recovery from the current episode of the illness, however defined, 52 weeks after randomization. We used logistic regression modelling to compare treatments.

RESULTS

The percentages (number/total) meeting trial criteria for recovery were 22% (32/143) after CBT, 22% (32/143) after GET, 8% (12/149) after APT and 7% (11/150) after SMC. Similar proportions met criteria for clinical recovery. The odds ratio (OR) for trial recovery after CBT was 3.36 [95% confidence interval (CI) 1.64–6.88] and for GET 3.38 (95% CI 1.65–6.93), when compared to APT, and after CBT 3.69 (95% CI 1.77–7.69) and GET 3.71 (95% CI 1.78–7.74), when compared to SMC (p values < or =0.001 for all comparisons). There was no significant difference between APT and SMC. Similar proportions recovered in trial subgroups meeting different definitions of the illness.

CONCLUSIONS

This study confirms that recovery from CFS is possible, and that CBT and GET are the therapies most likely to lead to recovery.

Spine kinematics predict symptom and lost time recurrence: how much recovery is enough?

PURPOSE

The purpose of the study was to determine thresholds for low back kinematic measures for the amount of functional recovery necessary to reduce the risk of recurrent pain symptoms or lost time.

METHODS

Low back kinematic ability measures were collected at baseline when the workers returned to work for full duty. The range of motion, velocity, and acceleration were collected using the lumbar motion monitor.

RESULTS

Follow-up data was collected on 196 of the 206 workers. Workers with sagittal extension velocity of <40 deg./s at baseline were twice as likely to report recurrent low back pain symptoms. Workers with sagittal flexion velocity <34 deg./s were 3 times more likely to report lost time.

CONCLUSIONS

Kinematic functional performance measures may be used as recovery criteria in low back pain patients to minimize recurrence risk.

The influence of self-reported leisure time physical activity and the body mass index on recovery from persistent back pain among men and women: a population-based cohort study

BACKGROUND

There is limited knowledge about leisure time physical activity and the body mass index (BMI) as prognostic factors for recovery from persistent back pain. The aim of this study was to assess the influence of leisure time physical activity and BMI on recovery from persistent back pain among men and women in a general population.

METHODS

The study population (n=1836) in this longitudinal cohort study consisted of participants reporting persistent back pain in the baseline questionnaire in 2002-2003. Data on leisure time physical activity, BMI and potential confounders were also collected at baseline. Information on recovery from persistent back pain (no back pain periods ≥ 7 days during the last 5 years) was obtained from the follow-up questionnaire in 2007. Log-binomial models were applied to calculate Risk Ratios with 95 percent Confidence Intervals (CI) comparing physically active and normal weight groups versus sedentary and overweight groups.

RESULTS

Compared to a sedentary leisure time, all measured levels of leisure time physical activity were associated with a greater chance of recovery from persistent back pain among women. The adjusted Risk Ratios was 1.46 (95% CI: 1.06, 2.01) for low leisure time physical activity, 1.51 (95% CI: 1.02, 2.23) for moderate leisure time physical activity, and 1.67 (95% CI: 1.08, 2.58) for high leisure time physical activity. There were no indications that leisure time physical activity influenced recovery among men, or that BMI was associated with recovery from persistent back pain either among men or among women.

CONCLUSIONS

Regular leisure time physical activity seems to improve recovery from persistent back pain among women.

Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?

BACKGROUND

Recovery from low back pain (LBP) is multidimensional and requires the use of multiple-response (outcome) measures to fully reflect these many dimensions. Predictive prognostic variables that are present or stable in all or most predictive models that use different outcome measures could be considered "universal" prognostic variables.

OBJECTIVE

The aim of this study was to explore the potential of universal prognostic variables in predictive models for 4 different outcome measures in patients with mechanical LBP.

DESIGN

Predictive modeling was performed using data extracted from a randomized controlled trial. Four prognostic models were created using backward stepwise deletion logistic, Poisson, and linear regression.

METHODS

Data were collected from 16 outpatient physical therapy facilities in 10 states. All 149 patients with LBP were treated with manual therapy and spine strengthening exercises until discharge. Four different measures of response were used: Oswestry Disability Index and Numeric Pain Rating Scale change scores, total visits, and report of rate of recovery.

RESULTS

The set of statistically significant predictors was dependent on the definition of response. All regression models were significant. Within both forms of the 4 models, meeting the clinical prediction rule for manipulation at baseline was present in all 4 models, whereas no irritability at baseline and diagnosis of sprains and strains were present in 2 of 4 of the predictive models.

LIMITATIONS

The primary limitation is that this study evaluated only 4 of the multiple outcome measures that are pertinent for patients with LBP.

CONCLUSIONS

Meeting the clinical prediction rule was prognostic for all outcome measures and should be considered a universal prognostic predictor. Other predictive variables were dependent on the outcomes measure used in the predictive model.

Prognostic factors for non-success in patients with sciatica and disc herniation

BACKGROUND

Few studies have investigated prognostic factors for patients with sciatica, especially for patients treated without surgery. The aim of this study was to identify factors associated with non-success after 1 and 2 years of follow-up and to test the prognostic value of surgical treatment for sciatica.

METHODS

The study was a prospective multicentre observational study including 466 patients with sciatica and lumbar disc herniation. Potential prognostic factors were sociodemographic characteristics, back pain history, kinesiophobia, emotional distress, pain, comorbidity and clinical examination findings. Study participation did not alter treatment considerations for the patients in the clinics. Patients reported on the questionnaires if surgery of the disc herniation had been performed. Uni- and multivariate logistic regression analyses were used to evaluate factors associated with non-success, defined as Maine-Seattle Back Questionnaire score of ≥5 (0-12) (primary outcome) and Sciatica Bothersomeness Index ≥7 (0-24) (secondary outcome).

RESULTS

Rates of non-success were at 1 and 2 years 44% and 39% for the main outcome and 47% and 42% for the secondary outcome. Approximately 1/3 of the patients were treated surgically. For the main outcome variable, in the final multivariate model non-success at 1 year was significantly associated with being male (OR 1.70 [95% CI; 1.06 - 2.73]), smoker (2.06 [1.31 - 3.25]), more back pain (1.0 [1.01 - 1.02]), more comorbid subjective health complaints (1.09 [1.03 - 1.15]), reduced tendon reflex (1.62 [1.03 - 2.56]), and not treated surgically (2.97 [1.75 - 5.04]). Further, factors significantly associated with non-success at 2 years were duration of back problems >; 1 year (1.92 [1.11 - 3.32]), duration of sciatica >; 3 months (2.30 [1.40 - 3.80]), more comorbid subjective health complaints (1.10 [1.03 - 1.17]) and kinesiophobia (1.04 [1.00 - 1.08]). For the secondary outcome variable, in the final multivariate model, more comorbid subjective health complaints, more back pain, muscular weakness at clinical examination, and not treated surgically, were independent prognostic factors for non-success at both 1 and 2 years.

CONCLUSIONS

The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica. This calls for a broader assessment of patients with sciatica than the traditional clinical assessment in which mainly the physical symptoms and signs are investigated.

Absence of low back pain in patients followed weekly over one year with automated text messages

BACKGROUND

In order to define the onset of a new episode of low back pain (LBP), the definition of a "non-episode" must be clear. De Vet et al reviewed the scientific literature but found no evidence-based definitions of episodes or non-episodes of LBP. However, they suggested that pain-based episodes should be preceded and followed by a period of at least one month without LBP. As LBP is an episodic disease, it is not clear whether a sufficient number of patients with LBP will be LBP-free for at least one month ("non-episode") to justify the use of this duration in the definition of pain free episode.

OBJECTIVES

Two clinical populations were followed weekly over one year making it possible 1) to determine the maximum numbers in a row of weeks without LBP, 2) to determine the prevalence of non-episodes throughout a one-year period, and 3) to find the prevalence of patients who reported to be in a non-episode of LBP at the end of the study.

METHODS

Secondary data were used from two recent clinical studies, in which weekly automated text messages (SMSes) had been collected on the number of days with LBP in the preceding week for one year. Weeks with 0 days of LBP were defined as "zero-weeks" and four zero-weeks in a row were defined as a period without LBP (a"non-episode") according to de Vet et al's suggestion. The study participants, all from the secondary care sector, consisted of: study 1) patients with LBP and Magnetic Resonance Imaging-identified Modic changes and study 2) patients without obvious acute disc problems, Modic changes or other pathologies, who therefore were assumed to have non-specific LBP. Both studies were two-armed intervention studies without a significant difference in outcome between intervention groups. The number of zero-weeks was identified in each participant. Thereafter the numbers of participants who reported at least one non-episode during the study period were identified. Finally, the numbers of participants who had a non-episode at the end of the study were counted. Estimates are reported with their 95% confidence intervals.

RESULTS

The numbers of participants included in the analyses were 80 and 209. Most commonly, no zero weeks were reported, by 65% (55-75) and 56% (49-63) of patients, respectively. The percentages of study participants with at least one non-episode at some time during the course of the study were 20% (11-29) and 18% (15-21. The percentages of participants who were identified as being in a non-episode at the time of the last week of the study were, 5% (95% CI: 0-10) and 4% (1-7) respectively.

CONCLUSIONS

The vast majority of these secondary care sector patients had a profile of more or less constant LBP. The estimates for non-episodes during the study period and at the end of the study were very similar for participants with LBP who also had Modic changes and those with non-specific LBP. It is possible that a definition of pain-free periods is pointless in patients seeking care in the secondary care sector.

Standardized measurement of recovery from nonspecific back pain

OBJECTIVE

To propose standardized, patient-centered measures of recovery from nonspecific low back pain (LBP) in research, underpinned by an empirically derived concept of recovery and informed by expert opinion.

DESIGN

Synthesis of literature reviews and expert panel opinion.

SETTING

Primary care centers for the management of nonspecific LBP.

PARTICIPANTS

Persons with nonspecific LBP.

INTERVENTIONS

Conservative treatments for nonspecific LBP.

MAIN OUTCOME MEASURES

Three phases of research were conducted. First, qualitative research that explored patients' perspectives of recovery from nonspecific LBP was reviewed. Second, measures of recovery used in LBP clinical trials during the past decade were investigated in a systematic review. Third, opinion was sought from an expert panel of clinicians and researchers about how to measure recovery from nonspecific LBP, in a workshop at the 10th International Forum for Primary Care Research in Low Back Pain.

RESULTS

An empirically derived and patient-centered concept of recovery from nonspecific LBP was developed from the qualitative research phase. The systematic review conducted in the second study phase revealed that researchers have used vastly heterogeneous measures of LBP recovery in clinical trials during the past decade. Finally, the key conclusions of the LBP Forum workshop were (1) that appropriate patient-centered instruments to measure recovery include global measures and patient-specific measures; and (2) that the benefits of implementing the same recovery measures for acute and chronic LBP outweigh the disadvantages of using different measures.

CONCLUSIONS

The results were synthesized to inform our recommendation that researchers consider adopting 2 instruments as standardized measures of recovery from nonspecific LBP, as an adjunct to the existing core set of LBP outcome measures. These instruments are an 11-point Global Back Recovery Scale, for a simple measure of global recovery, and the Patient-Generated Index of Quality of Life-Back Pain, to evaluate specific relevant dimensions of recovery. This recommendation has majority endorsement by members of the Australian National Health and Medical Research Council Acute Low Back Pain Review Group.

Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial

BACKGROUND

Motor control exercises to improve control and coordination of trunk muscles and graded activity under the principles of cognitive-behavioral therapy are 2 commonly used exercise therapies, yet there is little evidence to support the use of one intervention over the other.

OBJECTIVE

The objective of this study was to compare the effectiveness of motor control exercises and graded activity for patients with chronic nonspecific low back pain.

DESIGN

This study was a prospectively registered randomized controlled trial with outcome assessment and statistical analyses conducted blind to group.

SETTING

The study was conducted in primary care settings.

PATIENTS

The participants were 172 patients with chronic (>12 weeks) nonspecific low back pain.

INTERVENTIONS

Patients were randomly assigned to receive either motor control exercises or graded activity. There was no attempt to subclassify patients to match them to a treatment. Patients in both groups received 14 sessions of individualized, supervised exercise therapy.

MEASUREMENTS

Primary outcomes were average pain over the previous week (numeric rating scale) and function (Patient-Specific Functional Scale); secondary outcomes were disability (24-item Roland-Morris Disability Questionnaire), global impression of change (Global Perceived Effect Scale), and quality of life (36-Item Short-Form Health Survey questionnaire [SF-36]). Outcome measures were collected at baseline and at 2, 6, and 12 months after intervention.

RESULTS

A linear mixed models analysis showed that there were no significant differences between treatment groups at any of the time points for any of the outcomes studied. For example, the effect for pain at 2 months was 0.0 (-0.7 to 0.8).

LIMITATIONS

Clinicians could not be blinded to the interventions.

CONCLUSION

results of this study suggest that motor control exercises and graded activity have similar effects for patients with chronic nonspecific low back pain.