Clinical guidelines and care pathway for management of low back pain with or without radicular pain

Reliability, Concurrent Validity, and Clinical Performances of the Shorter Version of the Roland Morris Disability Questionnaire in a Sample of Italian People with Non-Specific Low Back Pain

BACKGROUND

Evaluating the psychometric and clinical performances of the RM-18, the shorter version of the Roland Morris Disability Questionnaire (RMQ), in Italian people with non-specific low back pain (NSLBP) as a time-saving and clinically useful method of assessing disability.

METHODS

This cross-sectional study included 74 people (52 females and 22 males, 53.03 ± 15.25 years old) with NSLBP. The RM-18, the RMQ, the Oswestry Disability Index (ODI), and a pain intensity numerical rating scale (NRS) were administered. Psychometric testing included reliability by internal consistency (Cronbach's alpha) and test-retest measurement (Intraclass Correlation Coefficient, ICC2.1), and concurrent validity by comparing the RM-18 with the RMQ and the ODI (Pearson's r correlation). Two separate regression analyses were performed to investigate the different impact of RM-18 and RMQ on NRS.

RESULTS

Cronbach's α of RM-18 was 0.92 and ICC (2,1) = 0.96. Strong correlations were found with the RMQ and the ODI (r = 0.98; r = 0.78, respectively). The regression models showed that the RM-18 and the RMQ similarly impacted the NRS (p < 0.001).

CONCLUSION

The RM-18 showed satisfactory psychometric testing and similarly impacted the NRS when compared to the RMQ. It can be recommended for clinical and research purposes in Italian people with NSLBP.

On-Site Physiotherapy in Emergency Department Patients Presenting with Nonspecific Low Back Pain: A Randomized Controlled Trial

Background: There is a high incidence of nonspecific Low Back Pain (LBP) in patients visiting Emergency Departments (EDs), but there is a lack of knowledge regarding emergency physiotherapy for LBP. The effect of on-site physiotherapy in these patients was therefore never demonstrated. We assessed short-term outcomes, feasibility and patient satisfaction with physiotherapy in ED patients presenting with nonspecific LBP. Methods: A block-randomized, controlled, open-label trial with a follow-up of 42 days. Patients aged 18 years or older presenting to an ED with nonspecific LBP were prospectively enrolled. Both groups received the same booklet with written information on LBP management and exercises. Patients in the intervention group were given additional instructions by a certified physiotherapist. Results: We included 86 patients in the primary analysis. The median age was 40, and 40.7% were female. At day 7, the median Oswestry Disability Index (ODI) was 2 points lower in the intervention group compared to the control group, which was not statistically significant. There was no between-group difference in pain at day 7. Patients who received physiotherapy felt significantly more confident with the exercises they were taught (p = 0.004, effect size = 0.3 [95% CI 0.1 to 0.5]). Conclusions: On-site physiotherapy in ED patients presenting with nonspecific low back pain is associated with higher patient satisfaction, compared to standard of care. The effect of physiotherapy was small, with only minimal improvement in disability, but without a reduction in pain. Despite the very small effect size, physiotherapeutic interventions should be investigated in larger cohorts with an extended intervention including patient education, exercises, and other physiotherapeutic modalities.

Efficacy of neuromobilization in the treatment of low back pain: Systematic review and meta-analysis

BACKGROUND

Low back pain (LBP) is a leading cause of disability. Neuromobilization (NM) as a physical therapy technique, offers some degree of symptom improvement. However, some studies have shown that NM can significantly reduce the symptoms of LBP, while others have failed to find similar positive effects.

OBJECTIVE

This study aims to investigate the effectiveness of NM for LBP.

DATA SOURCES

A literature search was conducted across five databases (MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science) from their inception to December 2023. Study main measures assessed pain, disability, and straight leg raise angle to determine the degree of improvement in patients.

RESULTS

Seven randomized controlled trials were included in the analysis. The findings indicated that NM interventions in patients with LBP were more effective than control groups in improving Visual Analog Scale scores (mean difference = 0.62, 95% CI (0.03, 1.21)) and Oswestry Disability Index scores (mean difference = 7.54, 95% CI (4.98, 10.10)). There was no significant difference in straight leg raise results (mean difference = 0.18, 95% CI (-0.08, 0.44)).

CONCLUSIONS

NM demonstrated effectiveness in improving Visual Analog Scale and Oswestry Disability Index outcomes in patients with LBP, but straight leg raise outcomes are still uncertain and until more high-quality studies are included, the effectiveness of NM for SLR remains unknown.

Recent clinical practice guidelines for the management of low back pain: a global comparison

BACKGROUND

Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world.

METHODS

MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture.

CONCLUSIONS

Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.

"Cooperation between physicians and physios fosters trust you know": a qualitative study exploring patients' experience with first-contact physiotherapy for low back pain in French primary care

BACKGROUND

Physiotherapists working in collaboration with family physicians in French multidisciplinary primary healthcare clinics are now able to manage acute low back pain patients as first-contact practitioners in advanced practice roles. This includes medical act delegation such as making a medical diagnosis and prescribing medication. The aim of this study is to explore patients' experience and perceptions when attending a first-contact physiotherapist (FCP) in an advanced practice collaborative primary care model for acute low back pain (LBP).

METHODS

A qualitative study using semi-structured interviews was conducted. Patients that consulted a FCP for acute LBP care in new collaborative model were included. Interviews were transcribed verbatim and inductive thematic analysis was performed to generate themes related to patients' experience and perceptions.

RESULTS

Ten patients were interviewed (3 women, 7 men; mean age 36.5 ± 9.63 years). All LBP participants experienced important level of pain and disability. Four overarching themes related to patients' experience with the new FCP model were formalized: 1) "Going to see a physiotherapist who specializes in painful movements, well that makes sense to me", 2) "Physiotherapist offered to give me exercises to do at home to relieve the back pain", 3) "I went there feeling confident", 4) "The physiotherapist can do more than just send you to see more appropriate people". Participants highlighted the need to receive timely and high-quality care and were receptive with being autonomously managed by a FCP. Overall, patients' experiences with FCP model of care were positive. Participants were highly confident in the FCP's ability to perform delegated medical tasks including making a medical diagnosis and prescribing oral medication such as analgesic drugs. Patients felt that a greater expansion of FCPs' scope of practice was needed to improve the model.

CONCLUSION

Findings from this study can inform the implementation of FCP in countries where patients are not typically granted FCP by underlining that patients are favourable towards the advance practice model as such models support timely and high-quality care. Further research is needed to better determine the future advance practice physiotherapists' scope of practice in French primary and secondary care settings.

BackMov: Individualized Motion Capture-Based Test to Assess Low Back Pain Mobility Recovery after Treatment

Low back pain (LBP) is a common issue that negatively affects a person's quality of life and imposes substantial healthcare expenses. In this study, we introduce the (Back-pain Movement) BackMov test, using inertial motion capture (MoCap) to assess lumbar movement changes in LBP patients. The test includes flexion-extension, rotation, and lateralization movements focused on the lumbar spine. To validate its reproducibility, we conducted a test-retest involving 37 healthy volunteers, yielding results to build a minimal detectable change (MDC) graph map that would allow us to see if changes in certain variables of LBP patients are significant in relation to their recovery. Subsequently, we evaluated its applicability by having 30 LBP patients perform the movement's test before and after treatment (15 received deep oscillation therapy; 15 underwent conventional therapy) and compared the outcomes with a specialist's evaluations. The test-retest results demonstrated high reproducibility, especially in variables such as range of motion, flexion and extension ranges, as well as velocities of lumbar movements, which stand as the more important variables that are correlated with LBP disability, thus changes in them may be important for patient recovery. Among the 30 patients, the specialist's evaluations were confirmed using a low-back-specific Short Form (SF)-36 Physical Functioning scale, and agreement was observed, in which all patients improved their well-being after both treatments. The results from the specialist analysis coincided with changes exceeding MDC values in the expected variables. In conclusion, the BackMov test offers sensitive variables for tracking mobility recovery from LBP, enabling objective assessments of improvement. This test has the potential to enhance decision-making and personalized patient monitoring in LBP management.

Development of a low back pain care pathway in an academic hospital system: results of a consensus process

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide and a significant component of healthcare expenditures. Clinical practice guidelines (CPGs) have been highlighted as a key resource to improve the quality of care. This study aimed to develop a clinical pathway for LBP based on CPGs in an academic health system.

METHODS

We conducted a modified Delphi study of clinicians caring for patients with LBP who were asked to rate 21 CPG-informed seed statements through an online survey. The goal was to identify statements that achieved a minimum of 80% consensus among panelists.

RESULTS

Thirty-five healthcare providers participated as panelists. The majority of participants were male (68.6%), had MD or DO (62.9%) degrees, and were clinicians (73.8%) working in neurosurgery (36.1%), orthopedics (25.7%), emergency medicine (14.3%), or physical therapy (11.4%). Initially, consensus was reached on 20 of 21 seed statements. One statement did not reach consensus in the initial round and was revised into two separate statements based on feedback from panelists. One of these statements achieved consensus in the second review round. All statements reaching consensus were incorporated into a care pathway consisting of diagnosis, evaluation, and treatment for LBP.

CONCLUSION

Healthcare providers across various disciplines supported statements interpreting current CPGs related to care for LBP. This study represents a step toward supporting guideline-concordant care for LBP. Additional research is needed to assess how such pathways impact actual clinical care.

Development and External Validation of Individualized Prediction Models for Pain Intensity Outcomes in Patients With Neck Pain, Low Back Pain, or Both in Primary Care Settings

OBJECTIVE

The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients with neck or low back pain in primary care settings.

METHODS

Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6 months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients' predictor information collected both at point of consultation and 2 to 4 weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance.

RESULTS

Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4 weeks after consultation (calibration slope = 0.848 [95% CI = 0.767 to 0.928] for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 [95% CI = 0.549 to 0.750]).

CONCLUSION

Model predictive accuracy was good when predictors were measured 2 to 4 weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance.

IMPACT

External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors.

Immediate effect of passive hamstring stretching on flexibility and relationship with psychosocial factors in people with chronic low back pain

Background

Hamstring muscle tightness contributes to disability in people with chronic low back pain (CLBP). HM stretching improves flexibility in healthy individuals, but the immediate effect of stretching is unknown in people with CLBP. Moreover, the stretching effect could be influenced by psychosocial factors.

Objectives

To evaluate the immediate effect of passive HM stretching on flexibility in people with CLBP and the relationships between psychosocial factors and change in hamstring flexibility.

Design

Non-randomized, pilot trial.

Method

One minute of passive stretching was performed in 90 people with CLBP. Change in Active Knee Extension and Straight Leg Raise angles (digital inclinometer), and Fingertips-to-Floor distance (measuring tape) were measured before and immediately after stretching. Correlations between change in flexibility and baseline Fear-Avoidance Beliefs Questionnaire (FABQ) and Hospital Anxiety and Depression Scale (HADS) scores were analyzed.

Results

Hamstring flexibility improved significantly after stretching; Active Knee Extension mean difference was 4° (95% CI, 2.4 to 5.1; p < 0.001, right ES = 0.24, left ES = 0.23); Straight Leg Raise mean difference was 7° (95% CI, 5.5 to 8.6, p < 0.001, right ES = 0.44, left ES = 0.42), Fingertips-to-Floor mean difference was 2 cm (95% CI, 1.7 to 3.0, p < 0.001, ES = 0.20). No correlation was found between improvement in any of the hamstring flexibility measurements and FABQ or HADS scores (p > 0.05).

Conclusions

Passive hamstring stretching induced an immediate, statistically significantly improvement in hamstring flexibility, but only the change in Straight Leg Raise amplitude was clinically important. Psychosocial factors were not related to improvements in flexibility after hamstring stretching.

A multidimensional nomogram combining clinical factors and imaging features to predict 1-year recurrence of low back pain with or without radicular pain after spinal manipulation/mobilization

BACKGROUND

In this retrospective study, we aimed to develop a nomogram to predict recurrence during a 1-year period of spinal manipulation/mobilization (SM/M) in patients with low back pain (LBP) with greater pain intensity, more severe comorbid conditions, or a neuropathic component.

METHODS

A total of 786 consecutive patients with LBP treated with SM/M as primary therapy were divided into training (n = 545) and validation (n = 241) sets. Cox regression analyses were used to assess the relative value of clinical factors and lumbar magnetic resonance imaging features associated with recurrence during the 1-year period. Predictors of recurrence with significant differences were used to construct a nomogram in the training set. We evaluated the performance of the model on the training and validation sets to determine its discriminative ability, calibration, and clinical utility. The prognostic value of the nomogram for predicting recurrence was assessed using Kaplan-Meier analysis and time-dependent receiver operating characteristic analyses.

RESULTS

A nomogram comprising hospitalization time, previous history of LBP, disease duration, lumbar range of motion, lower extremity tendon reflex, muscle strength, ratio of herniation to uncompressed dural sac area, and Pfirrmann classification was established for recurrence during a 1-year period after SM/M in patients with LBP. Favorable calibration and discrimination were observed in the nomogram training and validation sets (C-index 0.753 and 0.779, respectively). Decision curve analysis confirmed the clinical utility of the nomogram. Over a 1-year period, the nomogram showed satisfactory performance in predicting recurrence in LBP after SM/M.

CONCLUSION

We established and validated a novel nomogram that can accurately predict a patient's risk of LBP recurrence following SM/M. This realistic prognostic model may aid doctors and therapists in their decision-making process and strategy optimization for non-surgical treatment of LBP using SM/M.

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.

Between guidelines and clinical trials: evidence-based advice on the pharmacological management of non-specific chronic low back pain

The pharmacological management of nonspecific chronic low back pain (NCLBP) aims to restore patients' daily activities and improve their quality of life. The management of NCLBP is not well codified and extremely heterogeneous, and residual symptoms are common. Pharmacological management should be considered as co-adjuvant to non-pharmacological therapy, and should be guided by the symptoms reported by the patients. Depending on the individual severity of NCLPB, pharmacological management may range from nonopioid to opioid analgesics. It is important to identify patients with generalized sensory hypersensitivity, who may benefit from dedicated therapy. This article provides an evidence-based overview of the principles of pharmacological management of NCLPB.

Chronic Low Back Pain: A Narrative Review of Recent International Guidelines for Diagnosis and Conservative Treatment

Chronic low back pain (cLBP) is a public and occupational health problem that is a major professional, economic and social burden. We aimed to provide a critical overview of current international recommendations regarding the management of non-specific cLBP. We conducted a narrative review of international guidelines for the diagnosis and conservative treatment of people with non-specific cLBP. Our literature search yielded five reviews of guidelines published between 2018 and 2021. In these five reviews, we identified eight international guidelines that fulfilled our selection criteria. We added the 2021 French guidelines into our analysis. Regarding diagnosis, most international guidelines recommend searching for so-called yellow, blue and black flags, in order to stratify the risk of chronicity and/or persistent disability. The relevance of clinical examination and imaging are under debate. Regarding management, most international guidelines recommend non-pharmacological treatments, including exercise therapy, physical activity, physiotherapy and education; however, multidisciplinary rehabilitation, in selected cases, is the core treatment recommended for people with non-specific cLBP. Oral, topical or injected pharmacological treatments are under debate, and may be offered to selected and well-phenotyped patients. The diagnosis of people with cLBP may lack precision. All guidelines recommend multimodal management. In clinical practice, the management of individuals with non-specific cLBP should combine non-pharmacological and pharmacological treatments. Future research should focus on improving tailorization.

A national media mass campaign improves beliefs and behaviours about low back pain in the general population and in general practitioners

INTRODUCTION

Previous international mass-media campaigns for low back pain (LBP) have had conflicting impacts on the general population. The objective was to evaluate the impact of a national back pain campaign conducted between 2017 and 2019 on beliefs and behaviours of general practitioners and the general population in France.

METHODS

Between 2017 and 2019, a mass-media campaign was used to disseminate positive messages about LBP using several media, along with a parallel campaign addressed to general practitioners. An email survey before the campaign and 6 and 18 months after the campaign started evaluated beliefs and behaviours among a representative sample of the 2 target populations (3500 people from the general population and 700 general practitioners before the campaign, and 2000 people and 300 general practitioners 6 and 18 months after).

RESULTS

Overall, 56% of the general population respondents before the campaign and 74% and 75% at 6 and 18 months after adhered to the statement "One should maintain physical activity" when dealing with LBP. Conversely, the percentage adhering to the statement "The best treatment is resting" decreased significantly from 68% before the campaign to 45% at 6 and 18 months after. Physicians reported delivering more reassurance and giving more documentation to patients after the campaign. They prescribed less sick leave during the first consultation (65% before the campaign, 46% and 30% at 6 and 18 months after).

CONCLUSION

A mass-media campaign aimed at the public and general practitioners in France significantly modified beliefs and behaviours about LBP.

Measurement of Force and Intramuscular Pressure Changes Related to Thrust Spinal Manipulation in an In Vivo Animal Model

Current knowledge regarding biomechanical in vivo deep tissue measures related to spinal manipulation remain somewhat limited. More in vivo animal studies are needed to better understand the effects viscoelastic tissue properties (i.e., dampening) have on applied spinal manipulation forces. This new knowledge may eventually help to determine whether positive clinical outcomes are associated with particular force thresholds reaching superficial and/or deep spinal tissues. A computer-controlled feedback motor and a modified Activator V device with a dynamic load cell attached were used to deliver thrust spinal manipulations at various magnitudes to the L7 spinous process in deeply anesthetized animals. Miniature pressure catheters (Millar SPR-1000) were inserted unilaterally into superficial and deep multifidi muscles. Measurements of applied mechanical forces and superficial/deep multifidi intramuscular pressure changes were recorded during spinal manipulations delivered in vivo. Manipulative forces and net changes in intramuscular pressures reaching deep spinal tissues are greatly diminished by viscoelastic properties of in vivo tissues, which could have possible clinical safety and/or mechanistic implications.

Risk-based stratified primary care for common musculoskeletal pain presentations: qualitative findings from the STarT MSK cluster randomised controlled trial

BACKGROUND

The STarT MSK cluster randomised controlled trial (RCT) investigated the clinical- and cost-effectiveness of risk-based stratified primary care versus usual care for patients with back, neck, shoulder, knee or multi-site pain. Trial quantitative results showed risk-based stratified care was not superior to usual care for patients' clinical outcomes, but the intervention led to some changes in GP clinical decision-making. This paper reports a linked qualitative study exploring how risk-based stratified care was perceived and used in the trial, from the perspectives of clinicians and patients.

METHODS

Semi-structured interviews were conducted with 27 patients, and focus groups and interviews with 20 clinicians (GPs and physiotherapists) in the intervention arm of the trial. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and the COM-B model.

MAIN FINDINGS

Risk-based stratified care (subgrouping and matching treatments) was found to have 'coherence' (i.e. made sense) to several clinicians and patients, in that it was well-integrated in practice, and supported clinical decision-making. However, for some GPs stratified care was less 'meaningful', as the risk-stratification tool did not fit with usual ways of consulting and added to already time-pressured consultations. GPs reported giving more patients written information/advice due to easier access to electronic information leaflets through the trial template and were motivated to refer patients to physiotherapy as they believed the trial resulted in faster physiotherapy access (although this was not the case). Patients and clinicians reported that risk-based stratified care influenced conversations in the consultation, prompting greater attention to psychosocial factors, and facilitating negotiation of treatment options. Physiotherapists saw benefits in receiving information about patients' risk subgroup on referral forms.

CONCLUSION

These findings provide context for interpreting some of the trial outcomes, particularly in relation to changes in clinical decision-making when risk-based stratified care was used. Findings also indicate potential reasons for lack of GP engagement with risk-based stratified care. Positive outcomes were identified that were not captured in the quantitative data, specifically that risk-based stratified care positively influenced some GP-patient conversations and facilitated negotiation of treatment options.

TRIAL REGISTRATION

ISRCTN15366334 (26/04/2016).

Patient perspectives of care pathways for people with low back pain: A qualitative study

BACKGROUND

Low back pain (LBP) care pathways aim to enhance health outcomes through patient-clinician mutual decision-making and care coordination. However, challenges to successful translation into practice include patients' understanding, expectation, and acceptance of treatment and management strategies for LBP. This study explored patients' perspectives and/or experience of care pathways and their involvement in decision-making in primary care.

METHODS

A qualitative descriptive design was adopted. Semi-structured interviews were conducted with 14 participants with LBP recruited from the community. Inductive thematic analysis of the qualitative data was conducted within the design framework to enable a systematic comparison of experiences across participants and within individual cases.

RESULTS

Five themes described participant perspectives and understanding of care pathways: i) care pathways can guide decision-making; ii) familiarity with no and/or stepped care pathway, but preference for matched or blend of care pathways; iii) engaging in shared decision-making; iv) patient-related barriers to implementation; v) patient-related facilitators to implementation.

CONCLUSIONS

Participants felt that existing care pathways did not meet their needs when pain persisted. Participants preferred matched or hybrid care pathways and suggested that implementation of such pathways should focus on addressing an individual's needs. Adopting a holistic approach, and clarity in shared decision-making, were deemed crucial for effective implementation of LBP pathways in practice. Consumer (patient) engagement in the design of LBP care pathways is recommended.

Identification of Responders to Balneotherapy among Adults over 60 Years of Age with Chronic Low Back Pain: A Pilot Study with Trajectory Model Analysis

Balneotherapy may be a relevant treatment for chronic low back pain (LBP) in individuals > 60 years old. This pilot study aimed to determine the effectiveness of balneotherapy for chronic LBP in people > 60 years old and to determine profiles of responders with trajectory model analysis. This was a pilot prospective open cohort study, with repeated measurements using validated questionnaires; participants were their own controls. The primary endpoint was the proportion of participants with a change in pain intensity between the start of treatment and 3 months after treatment assessed with a numeric scale (NS) from 0 to 100 mm, with an effect size (ES) > 0.5. The assessments involved questionnaires that were self-administered on days (D) 1 and 21 and at months 3 and 6. The secondary objective was to determine the profile of responders to balneotherapy. We included 78 patients (69.2% women), mean age 68.3 ± 5.3 years. The mean pain score on the NS was 48.8 ± 19.9 at D1 and 39.1 ± 20.5 at 3 months (p < 0.001). The ES was 0.47 [95% confidence interval [CI] 0.25 to 0.69] for the whole sample; 36% (28/78) had an ES > 0.5; 23% (18/78) had a moderate ES (0 to 0.5); and 41% (32/78) had an ES of zero (14/78) or < 0 (18/78), corresponding to increased pain intensity. The pain trajectory model showed that the change in pain between D1 and D21 for trajectory A (larger reduction in pain intensity) was -50% [95% CI -60 to -27], and for trajectory B (smaller reduction in pain intensity), it was -13% [-33 to 0] (p < 0.001). Between Day 1 and month 3, the change for trajectory A was -33% [-54; 0] and for trajectory B was -13% [-40 to 0] (p = 0.14). Finally, between D1 and month 6, the change for trajectory A was -50% [-60 to 0] and for trajectory B was -6% [-33 to 17] (p = 0.007). The patients in trajectory A reported performing more physical activity than those in trajectory B (p = 0.04). They were also less disabled, with a mean Oswestry Disability Index of 40.4 versus 45.7 for those in trajectory A and B, respectively, (p = 0.03) and had a higher total Arthritis Self-Efficacy Scale score. This real-life study of the effectiveness of balneotherapy on chronic LBP identified distinct pain trajectories and predictive variables for responders. These criteria could be used in decision-making regarding the prescription of balneotherapy, to ensure personalized management of chronic LBP.

Spine abnormalities associated with bone edema on sacroiliac joints MRI in patients with non-inflammatory chronic back pain

OBJECTIVE

To investigate whether bone marrow edema (BME) fulfilling the ASAS definition of magnetic resonance imaging (MRI) sacroiliitis is associated with non-inflammatory spine abnormalities in patients with definite mechanical chronic back pain (CBP).

METHODS

Patients with definite mechanical CBP, according to the physician, started before the age of 45 and be lasting for more than 3months but less than 3years underwent a protocolized MRI and radiographs of sacroiliac joint (SIJ) and spine. BME and structural changes were scored, by three readers, for SIJ as well as non-inflammatory abnormalities for spine, including degenerative lesions and static disorders. Univariate analysis by Chi² test was performed to search a statistical association between BME fulfilling the ASAS definition of MRI sacroiliitis and the presence of at least one non-inflammatory spine abnormality.

RESULTS

A total of 94 patients were analyzed, 27 (29%) patients had BME and 16 (17%) patients had BME fulfilling the ASAS definition of MRI sacroiliitis; 86 (91.5%) patients had at least one non-inflammatory spine abnormality which are associated into 3 distinct clusters. BME was slightly more frequent at the lower and posterior part of the SIJ. MRI sacroiliitis was associated with interspinous bursitis, facet joint effusion and lateral spinal deviation and was more likely in patients with at least one non-inflammatory spine abnormality (OR: 4.96, 95% CI [1.47; 16.72]).

CONCLUSIONS

BME fulfilling the ASAS definition of MRI sacroiliitis is significantly associated with non-inflammatory spine abnormalities in patients with mechanical CBP.

A cross-sectional study to validate an administrative back pain severity classification tool based on the graded chronic pain scale

Treatment of chronic lower back pain (CLBP) should be stratified for best medical and economic outcome. To improve the targeting of potential participants for exclusive therapy offers from payers, Freytag et al. developed a tool to classify back pain chronicity classes (CC) based on claim data. The aim of this study was to evaluate the criterion validity of the model. Administrative claim data and self-reported patient information from 3,506 participants (2014-2021) in a private health insurance health management programme in Germany were used to validate the tool. Sensitivity, specificity, and Matthews' correlation coefficient (MCC) were calculated comparing the prediction with actual grades based on von Korff's graded chronic pain scale (GCPS). The secondary outcome was an updated view on direct health care costs (€) of patients with back pain (BP) grouped by GCPS. Results showed a fair correlation between predicted CC and actual GCPS grades. A total of 69.7% of all cases were correctly classified. Sensitivity and specificity rates of 54.6 and 76.4% underlined precision. Correlation between CC and GCPS with an MCC of 0.304 also indicated a fair relationship between prediction and observation. Cost data could be clearly grouped by GCPS: the higher the grade, the higher the costs and the use of health care. This was the first study to compare the predicted severity of BP using claim data with the actual severity of BP by GCPS. Based on the results, the usage of CC as a single tool to determine who receives CLBP treatment cannot be recommended. CC is a good tool to segment candidates for specific types of intervention in BP. However, it cannot replace a medical screening at the beginning of an intervention, as the rate of false negatives is too high. Trial registration The study was conducted using routinely collected data from an intervention, which was previously evaluated and registered retrospectively in the German Registry of Clinical Trials under DRKS00015463 (04/09/2018). Informed consent and the self-reported questionnaire have remained unchanged since the study and, therefore, are still valid according to the ethics proposal.

Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France

Objectives

To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.

Methods

This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.

Results

Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).

Conclusions

We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.

Trial registration

ClinicalTrials.gov: NCT04177121

Extracorporeal Shockwave Therapy for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To assess the effectiveness and safety of extracorporeal shockwave therapy (ESWT) for the treatment of chronic low back pain (CLBP).

METHODS

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement standard. We identified relevant studies by searching multiple electronic databases, trial registries, and websites up to April 30, 2021, and examining reference lists. We selected RCTs that compared ESWT, in unimodal or multimodal therapeutic approaches, with sham ESWT or other active therapies. Two investigators independently extracted data and assessed the risk of bias and quality of the evidence. The main outcomes were pain intensity and disability status, examined as standardized mean differences (SMD) with 95% confidence intervals (CI). The risk of bias was assessed by using Cochrane Back and Neck (CBN) Group risk of bias tool and Jadad score, and GRADE was applied to determine the confidence in effect estimates. Heterogeneity was explored using sensitivity analysis and meta-regression.

RESULTS

Ten RCTs, including a total of 455 young to middle-aged individuals (29.2-55.8 years), were identified. Compared with control, the ESWT group showed lower pain intensity at month 1 (SMD = -0.81, 95% CI -1.21 to -0.42), as well as lower disability score at month 1 (SMD = -1.45, 95% CI -2.68 to -0.22) and at month 3 (SMD = -0.69, 95% CI -1.08 to -0.31). No serious shockwave-related adverse events were reported.

CONCLUSION

The use of ESWT in CLBP patients results in significant and quantifiable reductions in pain and disability in the short term. However, further well-conducted RCTs are necessary for building high-quality evidence and promoting the application of ESWT in clinical practice.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.