Standardized measurement of recovery from nonspecific back pain

Confirmation of the Unidimensionality of the Satisfaction and Recovery Index Among Those With Various Musculoskeletal Disorders

Background A semistructured patient-reported outcome measure (PROM) wherein patients rate the importance of structured items and the magnitude of the psychometric properties to be investigated (e.g., disability and satisfaction) facilitates patient engagement in their treatment and patient-centered clinical practice. The Satisfaction and Recovery Index (SRI) is one such semistructured PROM that was originally developed to measure recovery from a whiplash injury. Exploratory factor analysis demonstrated a one-factor structure among ambulatory community-dwelling people with traumatic musculoskeletal injuries. However, a confirmatory factor analysis has not been conducted among patients with various musculoskeletal disorders, and the internal structure of the SRI has not been established yet. Thus, this study aimed to investigate the internal structure of the SRI among patients with diverse musculoskeletal disorders. Methodology An anonymous survey was performed for patients who were referred for physical therapy for musculoskeletal disorders at a local orthopedic clinic. A confirmatory factor analysis was conducted. The goodness-of-fit criteria were as follows: chi-square/degree of freedom < 3, goodness-of-fit index > 0.90, adjusted goodness-of-fit index > 0.95, and root mean square error of approximation < 0.08. Results Data from 217 participants were analyzed. All goodness-of-fit criteria were satisfied. Conclusion This study confirmed the acceptable internal structure of the SRI among patients with diverse musculoskeletal disorders.

Efficacy and safety of traditional Chinese manual therapy (Tuina) in patients with non-specific chronic low back pain: a study protocol for a randomised controlled trial

INTRODUCTION

Non-pharmacological interventions play a crucial role in the management of non-specific chronic low back pain (NSCLBP). One prime example is Tuina, a traditional Chinese manual therapy that incorporates pressing, kneading and rubbing techniques to alleviate physical discomfort and enhance overall well-being. It serves as a widely used technique in China and other East Asian countries. However, the effectiveness and safety of Tuina for managing NSCLBP have not been substantiated through rigorous clinical research. We sought to carry out a randomised controlled trial with an open-label design, blinded assessors and parallel arms to assess the effectiveness and safety of Tuina as a treatment for NSCLBP. The trial aims to provide high-quality evidence regarding the efficacy and safety of Tuina in improving outcomes for patients with NSCLBP.

METHODS AND ANALYSIS

A total of 150 patients aged 18-60 years with NSCLBP will be recruited. Participants will be randomly assigned to one of the two groups. Both groups will receive standard health education. In addition, the treatment group will receive Tuina therapy, while the control group will participate in core stability exercises. Each group will undergo a total of 18 interventions over 6 weeks, with the interventions administered three times per week. The primary outcome measure is the patient's pain intensity, assessed using the Numerical Rating Scale, at week 6 following randomisation. Secondary outcomes encompass disability (measured by the Roland-Morris Disability Questionnaire), quality of life (assessed using the EuroQoL-5 dimensions questionnaire), adverse emotions (evaluated with the Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia and Depression Anxiety Stress Scale), biomechanical outcomes, socioeconomic indicators (medication use, healthcare utilisation and absenteeism), patient satisfaction, treatment adherence and other relevant factors.The statistical analysis will follow the intention-to-treat principle. Two-way repeated measures analysis of variance will be used to compare the clinical data across different time points within both groups.

ETHICS AND DISSEMINATION

The study protocol has received approval from the Ethics Committee of Shuguang Hospital, Shanghai University of Traditional Chinese Medicine (2023-1366-133-01). All study participants will be required to give written informed consent. The findings of the study will be submitted to a peer-reviewed journal for publication and presented at scientific conferences. Additionally, the participants will receive copies of the results.

TRIAL REGISTRATION NUMBER

ChiCTR2300076257.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project)

STUDY DESIGN

Multiround wiki-based Delphi expert panel survey.

OBJECTIVE

To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care."

METHODS

Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators.

RESULTS

From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided.

CONCLUSION

These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

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.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

International Registered Report Identifier (IRRID)

DERR1-10.2196/32457

Initial development of a patient-reported outcome measure of disability due to Katakori via evaluating patient comprehensibility and comprehensiveness

[Purpose] “Katakori” refers to a nonspecific symptom, including discomfort or dull pain, that is experienced around the occiput and that extends through the cervical spine to the acromion and scapular area. This study aimed to develop a patient-reported outcome measure of disability due to Katakori, namely the Katakori Disability Index, via evaluating patient comprehensibility and comprehensiveness. [Participants and Methods] We conducted a semi-structured interview among participants who had experienced Katakori consistently during the past month to examine patient comprehensibility and comprehensiveness; we particularly used the thinking-aloud method and cognitive debriefing to evaluate comprehensibility. [Results] We initially tested a provisional version of the Katakori Disability Index with 24 items using two 11-point numeric rating scales in a subset of 10 participants. Considering the issues identified concerning comprehensibility and comprehensiveness, we created a second draft of the Katakori Disability Index with two 6-point Likert scales, modified items, and four additional items. The second draft was tested in another subset of 10 participants. We eventually developed a 31-item Katakori Disability Index with modified instructions and items, two additional items, and a post-survey checklist; all these features addressed the concerns identified and suggestions obtained in the second round of interviews. [Conclusion] We developed a 31-item Katakori Disability Index with content validity.

Criterion validation and interpretability of the Single Assessment Numerical Evaluation (SANE) of self-reported recovery in patients with neck pain

BACKGROUND

The SANE is a PROM of recovery, which may assist clinicians in clinical decision-making and discharge planning. The psychometric measurement properties of the SANE have yet to be determined for neck pain.

OBJECTIVES

Threefold objectives included: 1)determine the numerical threshold for the SANE at which patients with neck pain determine their symptoms are acceptable; 2)determine the association between scores for the NDI and VAS, with the SANE; 3)determine the average number of visits, costs and value associated with the management of neck pain.

DESIGN

Longitudinal repeated measures cohort design.

METHODS

Threshold measures for self-reported recovery with the SANE anchored to the PASS were examined using ROC. PCC determined the relationship between the VAS/pain and NDI raw/percentage change scores and the SANE at discharge. Descriptive statistics were used for number of visits and cost. Value was calculated as the proportion of change on the NDI and VAS/$100 US dollars spent.

RESULTS

57 subjects completed full observation. ROC analysis indicates a threshold value of 82.5%(Sn = 56.0, Sp = 85.7,+LR = 1.68,-LR = 0.29) on the SANE with an AUC of 0.820(95%CI = 0.638, 1.00). A weak correlation was found between raw NDI(r = 0.39 p < 0.05)/Pain(r = 0.45 p < 0.05) scores and the SANE with a moderate correlation between percent change scores of NDI(r = 0.52 p < 0.05)/PAIN(r = 0.54 p < 0.05) and the SANE. The value proposition indicated cost of care amounted to a 10.5% and 12.9%; improvement in the NDI and pain scores/$100 spent.

CONCLUSIONS

Patients reporting greater than 82.5% on the SANE are likely to find their present status acceptable and potentially stop seeking care.

Goal attainment scaling for patients with low back pain in rehabilitation: A systematic review

BACKGROUND AND AIMS

Goal attainment scaling (GAS) has been widely applied to chronic conditions; however, only recently has it been used for patients with low back pain (LBP). The objectives of this systematic review were to (a) examine the characteristics and rigor of published studies of GAS in the rehabilitation of patients with LBP, (b) describe how GAS has been applied in patients with LBP, and (c) evaluate the responsiveness and validity of GAS as an outcome measure in patients with LBP.

METHODS

A systematic search of the CINAHL, PubMed, and MEDLINE databases was performed (1968 and 1 September 2020) in addition to hand searching. Studies including GAS procedures in patients with LBP during rehabilitation were included in the review. Two authors independently selected studies for inclusion and determined levels of evidence using the Oxford Levels of Evidence and rated each study for quality using the Newcastle-Ottawa scale and reporting transparency using the STROBE statement checklist.

RESULTS

Six Level IV and one Level III/IV study were included in this review (search produced 248 studies for review). These studies assessed GAS feasibility, validity, sensitivity, and association with other outcome measures in patients with LBP. Findings suggest that patients with LBP are able to identify and set individualized goals during GAS, while GAS may be more sensitive to change and may measure different aspects of the patient experience as compared with fixed-item patient-reported measures. Additionally, GAS may have a therapeutic effect while improving patient outcomes and may be associated with patient satisfaction.

CONCLUSION

Based on this review, GAS shows promise as a feasible patient-centered measure that may be more responsive to change than traditional outcome measures. However, GAS has been inadequately developed and validated for use during rehabilitation in patients with LBP.

The RESOLVE Trial for people with chronic low back pain: statistical analysis plan

BACKGROUND

Statistical analysis plans describe the planned data management and analysis for clinical trials. This supports transparent reporting and interpretation of clinical trial results. This paper reports the statistical analysis plan for the RESOLVE clinical trial. The RESOLVE trial assigned participants with chronic low back pain to graded sensory-motor precision training or sham-control.

RESULTS

We report the planned data management and analysis for the primary and secondary outcomes. The primary outcome is pain intensity at 18-weeks post randomization. We will use mixed-effects models to analyze the primary and secondary outcomes by intention-to-treat. We will report adverse effects in full. We also describe analyses if there is non-adherence to the interventions, data management procedures, and our planned reporting of results.

CONCLUSION

This statistical analysis plan will minimize the potential for bias in the analysis and reporting of results from the RESOLVE trial.

TRIAL REGISTRATION

ACTRN12615000610538 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368619).

Changes in pressure pain threshold and temporal summation in rapid responders and non-rapid responders after lumbar spinal manipulation and sham: A secondary analysis in adults with low back pain

BACKGROUND

People with LBP who experience rapid improvement in symptoms after spinal manipulative therapy (SMT) are more likely to experience better longer-term outcomes compared to those who don't improve rapidly. It is unknown if short-term hypoalgesia after SMT could be a relevant finding in rapid responders.

OBJECTIVES

We aimed to explore whether rapid responders had different short-term pressure pain threshold (PPT) and temporal summation (TS) outcomes after SMT and sham compared to non-rapid responders.

METHODS

This was a planned secondary analysis of a randomised controlled trial that recruited 80 adults with LBP (42 females, mean age 37 yrs). PPT at the calf, lumbar spine, and shoulder and TS at the hands and feet were measured before and three times over 30 min after a lumbar SMT or sham manipulation. Participants were classified as rapid responders or non-rapid responders based on self-reported change in LBP over the following 24 h.

RESULTS

Shoulder PPT transiently increased more in the rapid responders than non-rapid responders immediately post-intervention only (between-group difference in change from baseline = 0.29 kg/cm², 95% CI 0.02-0.56, p = .0497). There were no differences in calf PPT, lumbar PPT, hand TS, or foot TS based on responder status.

CONCLUSIONS

Hypoalgesia in shoulder PPT occurred transiently in the rapid responders compared to the non-rapid responders. This may or may not contribute to symptomatic improvement after SMT or sham in adults with LBP, and may be a spurious finding. Short-term changes in TS do not appear to be related to changes in LBP.

Cross-cultural adaptation and psychometric properties of the European Portuguese version of the Global Perceived Effect Scale in patients with chronic low back pain

PURPOSE

To cross-culturally adapt the Global Perceived Effect Scale (GPES) into Portuguese and investigate its psychometric properties in patients with chronic low back pain.

METHODS

Cross-cultural adaptation was carried out according to published guidelines. Along with measures for pain and disability, GPES was administered at baseline, 48-h later and post-intervention. To estimate test-retest reliability, the intraclass correlation coefficient was used. The validity was examined through the correlation between the GPES and the Patient Global Improvement Change Scale and the contribution of baseline status to GPES scores. Responsiveness was assessed by analyzing hypotheses regarding areas under the curve and correlations with changes in other measures.

RESULTS

The test-retest reliability, the convergent validity and the contribution of the baseline status to GPES scores were demonstrated. The EPES correlated strongly with global perception of change (r = 0.677), and moderately with pain and disability changes (r = 0.457 and r = 0.452, respectively). Areas under the curve values of 0.71(95% CI = 0.607-0.825) and 0.83 (95% CI = 0.749-922) were found.

CONCLUSION

The GPES demonstrated adequate psychometric properties. This study's findings supported its use in clinical and research studies with patients with chronic low back pain.IMPLICATIONS FOR REHABILITATIONThe European Portuguese version of the Global Perceived Effect Scale demonstrated adequate reliability, validity and responsiveness. This instrument is suitable to evaluate meaningful changes in patients with chronic low back pain.The contribution of baseline status to GPES scores was confirmed by specific and recommended methods. The use of the GPES as external criterion of change in clinimetric studies was supported.The minimum important change was 2.5 points out of 11 of the GPES. Only improvements above this point should be considered as relevant to patients with chronic low back pain undergoing physiotherapy.

Reporting on the level of validity and reliability of questionnaires measuring Katakori severity: A systematic review

Objectives:

Katakori is a Japanese term for non-specific symptoms including discomfort or dull pain caused by muscle stiffness around the neck through the shoulders and is one of the most frequently reported symptoms in Japan. However, there has been no standardized patient-reported outcome measure to evaluate Katakori severity. This study aimed to investigate the reporting level on validity and reliability of patient-reported outcome measures of Katakori severity.

Method:

A systematic search in ICHUSHI, MEDLINE, EMBASE and PubMed was undertaken from inception to April 2017 without language limitations. Two authors independently undertook screening by inspecting the title and abstract. Inclusion criteria were as follows: (1) participants with Katakori symptoms, (2) reporting reliability or validity of questionnaire evaluating Katakori severity and (3) published journal articles. Studies that either of the authors retained through the screening process were inspected with full text by the two authors independently to examine eligibility of the study. Any disagreement on eligibility after full-text inspection was resolved by discussion between them. Methodological quality was rated with the COnsensus-based Standards for the selection of health Measurement INstruments checklist. Subsequently, the evidence level of each measurement property was assessed for each questionnaire. The two authors extracted data independently. Any disagreement was resolved by discussion between them.

Results:

Five questionnaires were identified in five studies. The Shoulder Pain and Disability Index and Scale for Measuring Felt Shoulder Stiffness had the highest level of methodological quality. However, excellent measurement properties were found in only two out of nine criteria. Furthermore, in particular, content validity was not investigated in any measure.

Conclusion:

There is preliminary evidence for the reliability and validity of the Shoulder Pain and Disability Index and Scale for Measuring Felt Shoulder Stiffness; however, much further research is required. Identifying or developing a patient-reported outcome measure with content validity would be a future research agenda.

Effects of spinal manipulative therapy biomechanical parameters on clinical and biomechanical outcomes of participants with chronic thoracic pain: a randomized controlled experimental trial

BACKGROUND

Spinal manipulative therapy (SMT) includes biomechanical parameters that vary between clinicians, but for which the influence on the therapy clinical effects is unknown. This parallel-randomized controlled trial aimed to investigate the effect of SMT biomechanical parameters on the outcomes of participants with chronic thoracic pain (CTP) following three treatment sessions (follow-up at one week).

METHODS

Adults reporting CTP (pain within the evaluated region [T6 to T8] for ≥3 months) were asked to participate in a four-session trial. At the first session, participants were randomly assigned to one of three experimental groups (different SMT doses) or the control group (no SMT). During the first three sessions, one SMT was executed at T7 for the experimental groups, while a 5-min rest was provided to the control group. SMT were delivered through an apparatus using a servo-controlled linear actuator motor and doses consisted of peak forces, impulse durations, and rates of force application set at 135 N, 125 ms and 920 N/s (group 1), at 250 N, 125 ms and 1840 N/s (group 2), and at 250 N, 250 ms, 920 N/s (group 3). Disability and pain intensity were evaluated at each session (primary outcomes). Spinal stiffness was assessed before-and-after each SMT/rest and at follow-up. Tenderness and muscle activity were evaluated during each spinal stiffness trial. Improvement was evaluated at follow-up. Differences in outcomes between groups and sessions were evaluated as well as factors associated with clinical improvement.

RESULTS

Eighty-one participants were recruited and 17, 20, 20 participants of the three experimental groups and 18 of the control group completed the protocol. In exception of higher pain intensity at baseline in the control group, no between-group differences were found for any of the outcomes. A decrease in pain intensity, disability, spinal stiffness, and tenderness during spinal stiffness were observed (p-values< 0.05). At follow-up, 24% of participants were classified as 'improved'. Predictors of improvement were a greater decrease in pain intensity and in tenderness (p-values< 0.05).

CONCLUSIONS

In an experimental setting, the delivery of a SMT does not lead to significantly different outcomes in participants with CTP than a control condition (spinal stiffness assessment). Studies are still required to explore the mechanisms underlying SMT effects.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03063177 , registered 24 February 2017).

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.

The impact of psychological factors on condition-specific, generic and individualized patient reported outcomes in low back pain

Background

An individualized patient reported outcome (PRO) has recently been recommended within LBP research, but no study has evaluated this instrument with commonly applied PROs. Moreover, the impact of psychological factors has mostly been assessed for disease-specific instruments. The objective of this study was to assess the predictive value of illness perceptions, pain catastrophizing and psychological distress on 12 month outcomes assessed by specific, generic and individualized PROs recommended in low back pain (LBP).

Methods

Secondary analysis of patients with sub-acute or chronic LBP recruited for a cluster randomized controlled trial in primary care who completed a self-administered questionnaire at baseline and 12 months. 12 month scores for the Roland Morris Disability Questionnaire (RMDQ), the EuroQol (EQ-5D), and the Patient Generated Index (PGI) were dependent variables in hierarchical regression analysis. Independent variables included baseline scores for the Brief Illness Perceptions Questionnaire (Brief IPQ), Hopkins Symptom Check List (HSCL-25), Pain Catastrophizing Scale (PCS), health/clinical and sociodemographic variables.

Results

Of the 216 eligible patients included, 203 patients responded to the baseline questionnaire and 150 (74%) responded at 12 months. The mean age was 38.3 (SD 10.2) years and 57.6% were female. The Brief IPQ showed a statistically significant variation in the 12-months score of all the PROs, explaining 2.5% in RMDQ, 7.9% in EQ-5D, and 3.6% in PGI. Most of the explained variation for EQ-5D scores related to illness perceptions. The PCS explained 3.7% of the RMDQ and 2.5% in the EQ-5D scores. The HSCL-25 did not make a significant contribution.

Conclusion

Illness perceptions and pain catastrophizing were associated with 12-month outcomes as assessed by condition-specific, generic and individualized PROs. The Brief IPQ and PCS have relevance to applications in primary care that include interventions designed to enhance psychological aspects of health and where the contribution of such variables to outcomes is of interest. Further studies should assess whether the Brief IPQ perform similarly in LBP populations in other health care settings.

Evaluation of individualized quality of life and illness perceptions in low back pain. A patient education cluster randomized controlled trial

OBJECTIVE

To evaluate the effect of a cognitive patient education intervention compared with usual care on secondary outcomes of individual quality of life and psychological outcomes of illness perceptions and pain catastrophizing in patients with low back pain.

METHODS

A pragmatic cluster randomized controlled trial in which 16 general practitioners (GPs) and 20 physiotherapists (PTs) in primary care were randomly assigned to provide either a cognitive patient education intervention or usual treatment. Patients were followed up at 4 weeks and 12 months after treatment. Linear mixed models were used with group, time, type of clinician and interaction effects of group*time as fixed effects.

RESULTS

A total of 203 patients provided data at baseline, 86% responded at 4 weeks and 74% at 12 months. For all the outcome measures there was a statistically significant effect of time (p<0.001) and type of clinician (p<0.05) during the follow-up year. There was a significant interaction effect of group×time on illness perceptions (p=0.003), however not for the other outcome measures.

CONCLUSION

The cognitive patient education intervention initiated a faster improvement in illness perceptions but not in the other outcomes.

PRACTICE IMPLICATIONS

A patient education intervention can be beneficial to improve illness perceptions, however more research is needed.

A Systematic Review of Outcome Measures Use, Analytical Approaches, Reporting Methods, and Publication Volume by Year in Low Back Pain Trials Published between 1980 and 2012: Respice, adspice, et prospice

BACKGROUND

Increasing patient-reported outcome measures in the 1980s and 1990s led to the development of recommendations at the turn of the millennium for standardising outcome measures in non-specific low back pain (LBP) trials. Whether these recommendations impacted use is unclear. Previous work has examined citation counts, but actual use and change over time, has not been explored. Since 2011, there has been some consensus on the optimal methods for reporting back pain trial outcomes. We explored reporting practice, outcome measure use, and publications over time.

METHODS

We performed a systematic review of LBP trials, searching the European Guidelines for the management of LBP, extending the search to 2012. We abstracted data on publications by year, outcome measure use, analytical approach, and approaches taken to reporting trials outcomes. Data were analysed using descriptive statistics and regression analyses.

RESULTS

We included 401 trials. The number of published trials per year has increased by a factor of 4.5 from 5.4 (1980-1999) to 24.4 (2000-2012). The most commonly used outcome measures have been the Visual Analogue Scale for pain intensity, which has slowly increased in use since 1980/81 from 20% to 60% of trials by 2012, and the Roland-Morris Disability Questionnaire, which rose to 55% in 2002/2003, and then fell back to 28% by 2012. Most trialists (85%) report between-group mean differences. Few (8%) report individual improvements, and some (4%) report only within-group analyses. Student's t test, ANOVA, and ANCOVA regression, or mixed models, were the most common approaches to analysis.

CONCLUSIONS

Recommendations for standardising outcomes may have had a limited or inconsistent effect on practice. Since the research community is again considering outcome measures and modifying recommendations, groups offering recommendations should be cognisant that better ways of generating trialist buy-in may be required in order for their recommendations to have impact.

OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain. Trial protocol

INTRODUCTION

Low back pain and neck pain are extremely prevalent and are responsible for an enormous burden of disease globally. Strong analgesics, such as opioid analgesics, are recommended by clinical guidelines for people with acute low back pain or neck pain who are slow to recover and require more pain relief. Opioid analgesics are widely and increasingly used, but there are no strong efficacy data supporting the use of opioid analgesics for acute low back pain or neck pain. Concerns regarding opioid use are further heightened by the risks of adverse events, some of which can be serious (eg, dependency, misuse and overdose).

METHODS AND ANALYSIS

OPAL is a randomised, placebo-controlled, triple-blinded trial that will investigate the judicious use of an opioid analgesic in 346 participants with acute low back pain and/or neck pain who are slow to recover. Participants will be recruited from general practice and randomised to receive the opioid analgesic (controlled release oxycodone plus naloxone up to 20 mg per day) or placebo in addition to guideline-based care (eg, reassurance and advice of staying active) for up to 6 weeks. Participants will be followed-up for 3 months for effectiveness outcomes. The primary outcome will be pain severity. Secondary outcomes will include physical functioning and time to recovery. Medication-related adverse events will be assessed and a cost-effectiveness analysis will be conducted. We will additionally assess long-term use and risk of misuse of opioid analgesics for up to 12 months.

ETHICS AND DISSEMINATION

Ethical approval has been obtained. Trial results will be disseminated by publications and conference presentations, and via the media.

TRIAL REGISTRATION NUMBER

ACTRN12615000775516: Pre-results.

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)

Botlhoko, botlhoko! How people talk about their musculoskeletal complaints in rural Botswana: a focused ethnography

Background

Conflicting interpretations about the structure and function of the body contribute to discordance in communication between healthcare professionals and lay people. Understanding musculoskeletal (MSK) complaints presents additional complexities when discussed in more than one language or in cross-cultural settings. In low- and middle-income countries (LMICs), few healthcare professionals have specialist MSK training and not all practitioners speak the primary language of patients.

Objective

Our goal was to understand how people in rural Botswana perceive and express MSK complaints.

Design

Ethnographic fieldwork for 8 months in the Botswana Central District included participant observations and interviews with 34 community members with MSK complaints. Audio-recorded interviews were typically conducted in Setswana with an interpreter, transcribed verbatim, and contextually translated into English. Abductive qualitative analysis was used as the interpretive methodology.

Results

Whereas initial responses about MSK troubles yielded the exclamation botlhoko, botlhoko! combined with animated non-verbal gestures and facial expressions indicating widespread body pains, in-depth interviews revealed the complexities of pain expression among respondents. MSK pains were described as ‘bursting, exploding, aching, numbness, hot, pricking, stabbing, swollen, and pain in the heart’. Language subtleties manifested during interviews, where ‘meat’ or ‘flesh’ implied soft tissue pains; waist pains were voiced yet portrayed as low back or sacroiliac pain; and ‘veins’ variously referred to structural and functional types of pain. Psychological and social stressors accompanied many accounts of MSK troubles.

Conclusions

Respondents offered diverse MSK symptom descriptions consistent with biopsychosocial illness models, yet few communicated complaints using the biomedical language of healthcare providers. Although research interview and transcription processes may not be practical for clinicians, working with interpreters who communicate detailed patient accounts for MSK troubles will complement patient–provider encounters. Community member perceptions of their MSK pain and associated conditions should be explored and incorporated into healthcare interventions and innovations for rural communities in LMICs.

Patient led goal setting in chronic low back pain-What goals are important to the patient and are they aligned to what we measure?

OBJECTIVE

To determine the extent of alignment between clinical outcome measures and patient-derived goals for the management of chronic low back pain (cLBP).

METHODS

A customised, patient-led goal setting intervention was implemented facilitated by a physiotherapist, in which participants identified problem areas and developed strategies to address them. Patient goals were compared to the most commonly used outcome measures in cLBP as well as research outcomes recommended by the IMMPACT consortium.

RESULTS

From 20 participants, a total of 27 unique goals were identified, the most common goal related to physical activity (49%). Comparison of participant goals to the most common measures used by physiotherapists found none of the goals could be aligned. Comparison of goals and domains with IMPACCT outcome domains found 76% of the goals were aligned with physical functioning and 16% with emotional functioning.

CONCLUSION

This study has identified goals important to patients in cLBP, these were varied, and most did not correspond with current clinical measures.

PRACTICE IMPLICATIONS

Clinical outcome measures may not be providing accurate information about the success of treatments that are meaningful to the patient. Clinicians should consider a collaborative approach with cLBP patients to determine treatment interventions that are driven by patient preference.

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.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR REHABILITATION

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

Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability worldwide. Of those patients who present to primary care with acute LBP, 40% continue to report symptoms 3 months later and develop chronic LBP. Although it is possible to identify these patients early, effective interventions to improve their outcomes are not available. This double-blind (participant/outcome assessor) randomised controlled trial will investigate the efficacy of a brief educational approach to prevent chronic LBP in 'at-risk' individuals.

METHODS/ANALYSIS

Participants will be recruited from primary care practices in the Sydney metropolitan area. To be eligible for inclusion participants will be aged 18-75 years, with acute LBP (<4 weeks' duration) preceded by at least a 1 month pain-free period and at-risk of developing chronic LBP. Potential participants with chronic spinal pain and those with suspected serious spinal pathology will be excluded. Eligible participants who agree to take part will be randomly allocated to receive 2×1 h sessions of pain biology education or 2×1 h sessions of sham education from a specially trained study physiotherapist. The study requires 101 participants per group to detect a 1-point difference in pain intensity 3 months after pain onset. Secondary outcomes include the incidence of chronic LBP, disability, pain intensity, depression, healthcare utilisation, pain attitudes and beliefs, global recovery and recurrence and are measured at 1 week post-intervention, and at 3, 6 and 12 months post LBP onset.

ETHICS/DISSEMINATION

Ethical approval was obtained from the University of New South Wales Human Ethics Committee in June 2013 (ref number HC12664). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conference meetings.

TRIAL REGISTRATION NUMBER

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808.

"I know it's changed": a mixed-methods study of the meaning of Global Perceived Effect in chronic neck pain patients

PURPOSE

Global Perceived Effect (GPE) is a commonly used outcome measure for musculoskeletal conditions like neck pain; however, little is known regarding the factors patients take into account when determining their GPE. The overall objective of this work was to describe the thematic variables, which comprise the GPE from the patient's perspective.

METHODS

This was a mixed-methods study in which qualitative data were collected within a randomized clinical trial assessing exercise and manual therapy for chronic neck pain. A consecutive sample of 106 patients who completed the trial intervention took part in semi-structured interviews querying the meaning of GPE. Quantitative measures were collected through self-report questionnaires. Interview transcripts were analyzed using content analysis to identify themes, which were then quantified to assess potential relationships.

RESULTS

A model of GPE for chronic neck pain emerged comprised of five main themes: neck symptoms (cited by 85%), biomechanical performance (38%), activities of daily living (31%), self-efficacy (10%), and need for other treatment (6%). Influencing factors included those contributing to GPE: treatment process (64%), biomechanical performance (51%), self-efficacy (16%), and the nature of the condition (8%). Factors, which detracted from GPE or prevented recovery included perceived nature of condition (58%), required daily activities (10%), lack of diagnosis (5%), and history of failed treatment (5%).

CONCLUSIONS

GPE appears to capture chronic neck pain patient perceptions of change in different domains important to their individual pain experiences that may not be captured by other outcome instruments. Thus, GPE is a suitable patient-oriented outcome that can complement other measures in research and clinical practice. Importantly, many chronic neck pain patients believe it impossible to reach complete recovery because of a perceived intractable aspect of their neck condition; this has important implications regarding long-term disability and health-seeking behaviors.