The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF)

BACKGROUND

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.

AIM

To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.

DESIGN

Clinical practice guideline.

SETTING

Inpatient and outpatient.

POPULATION

Adults with LBP and/or LRS.

METHODS

Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.

RESULTS

The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.

CONCLUSIONS

An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.

CLINICAL REHABILITATION IMPACT

This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Clinical Occurrences in the Neurorehabilitation of Dogs with Severe Spinal Cord Injury

This prospective observational clinical study in a population of tetraplegic and paraplegic dogs (n = 488) with or without deep pain sensation, similar to humans ASIA A and B, investigated the prevalence of clinical occurrences in a rehabilitation center with a hospitalization regime between 15 days and 9 months. A checklist of occurrences was used for easy identification and monitoring, resulting in a total of 79.5% occurrences. There were 58% of dogs with neurogenic bladder, 35.5% with diarrhea, 21.3% with urinary incontinence, and 20.5% with fecal incontinence. A low incidence of respiratory problems (e.g., pneumonia) and urinary tract infections may suggest the efficacy of some applied measures in this study, such as thoracic and abdominal POCUS evaluation, positioning strategies, physical exercises, respiratory kinesiotherapy, and early implementation of a functional neurorehabilitation protocol. These can be essential measures to prevent clinical occurrences, mainly in breeds such as the French Bulldog and the Dachshund.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

Effectiveness of workplace intervention strategies in lower back pain prevention: a review

The aim of this study was to identify effective work place intervention strategies for the prevention of low back pain (LBP). The study focused on interventions to two major groups: personal interventions and technical interventions. Data basis were searched for with inclusion criteria: study design based on randomised controlled trial; outcome measures including non-specific LBP occurrence expressed by prevalence or intensity; intervention met the definition of the technical and/or personal (physical exercises, behavioural training, educational) intervention programme. Eighteen papers were selected for full analysis. The diversification of quantitative indicators of differences between control and intervention groups were carried out using Cohen's d index. The results of analysis showed strong differences in effects among intervention strategies, as well as among different cases within similar intervention strategies. LBP severity before intervention and the length of intervention were discussed as potentially influencing factors. The results of the analysis suggest that the most effective strategies for LBP prevention include technical modifications of the workstand and education based on practical training. Behavioural and physical training seems to be of lesser importance. LBP severity before intervention and the time when the measurements of outcome measures take place play an important role in the effectiveness of intervention.

Effects of physical therapy for temporomandibular disorders on headache pain intensity: A systematic review

BACKGROUND

Physical therapy is regarded an effective treatment for temporomandibular disorders (TMD). Patients with TMD often report concomitant headache. There is, however, no overview of the effect of physical therapy for TMD on concomitant headache complaints.

OBJECTIVES

The aim of this study is to systematically evaluate the literature on the effectiveness of physical therapy on concomitant headache pain intensity in patients with TMD.

DATA SOURCES

PubMed, Cochrane and PEDro were searched.

STUDY ELIGIBILITY CRITERIA

Randomized or controlled clinical trials studying physical therapy interventions were included.

PARTICIPANTS

Patients with TMD and headache.

APPRAISAL

The Cochrane risk of bias tool was used to assess risk of bias.

SYNTHESIS METHODS

Individual and pooled between-group effect sizes were calculated according to the standardized mean difference (SMD) and the quality of the evidence was rated using the GRADE approach.

RESULTS

and manual therapy on both orofacial region and cervical spine. There is a very low level of certainty that TMD-treatment is effective on headache pain intensity, downgraded by high risk of bias, inconsistency and imprecision.

LIMITATIONS

The methodological quality of most included articles was poor, and the interventions included were very different.

CONCLUSIONS

Physical therapy interventions presented small effect on reducing headache pain intensity on subjects with TMD, with low level of certainty. More studies of higher methodological quality are needed so better conclusions could be taken.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Exercise training in older adults, what effects on muscle force control? A systematic review of randomized clinical trials

AIM

To determine the magnitude of the effects of different exercise training (ET) modalities on variables of muscle force control in older adults.

METHODS

Relevant articles were searched in PubMed, Web of Science, Science Direct and Scopus, using the keywords: Aged AND "Exercise Movement Techniques" AND ("Complexity of torque" OR "Complexity of force" OR "Variability of torque" OR "Variability of force" OR "Force Steadiness" OR "Force fluctuations"). To be included in the full analysis, the studies had to be randomized controlled trials in which older adults were submitted to ET programs and muscle force control assessment.

RESULTS

The searches resulted in 702 articles from which 6 met all the inclusion criteria. The trials involved 171 healthy and functionally limited older adults (71.64 ± 1.53 years). Studies included resistance, steadiness and functional training programs. Training sessions were 2-3 time per week, lasted 6-16 months with intensities determined as percentage of the one repetition maximum loads. There is a heterogeneity regarding experimental set-up and data analysis parameters between studies. The findings show an improved muscle force control in older adults after ET. Such response is better evidenced by the assessment of the coefficient of variation (CV) of the force signals. There is moderate evidence that resistance training programs are effective to decrease CV of knee extensor force signals at lower force targets.

CONCLUSIONS

The findings from this review suggest that ET programs are effective to improve muscle force control in older adults.

Non-Specific Low Back Pain

BACKGROUND

For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition.

METHODS

The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process.

RESULTS

If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible.

CONCLUSION

A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

A Machine Learning-based Surface Electromyography Topography Evaluation for Prognostic Prediction of Functional Restoration Rehabilitation in Chronic Low Back Pain

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to investigate the feasibility and applicability of support vector machine (SVM) algorithm in classifying patients with LBP who would obtain satisfactory or unsatisfactory progress after the functional restoration rehabilitation program.

SUMMARY OF BACKGROUND DATA

Dynamic surface electromyography (SEMG) topography has demonstrated the potential use in predicting the prognosis of functional restoration rehabilitation for patients with low back pain (LBP). However, processing from raw SEMG topography to make prediction is not easy to clinicians.

METHODS

A total of 30 patients with nonspecific LBP were recruited and divided into "responding" and "non-responding" group according to the change of Visual analog pain rating scale and Oswestry Disability Index. Each patient received a 12-week functional restoration rehabilitation program. A normal database was calculated from a control group from 48 healthy participants. Root-mean-square difference (RMSD) was extracted from the recorded dynamic SEMG topography during symmetrical and asymmetrical trunk-movement. SVM and cross-validation were applied to the prediction based on the optimized features selected by the sequential floating forward selection (SFFS) algorithm.

RESULTS

RMSD feature parameters following rehabilitation in the "responding" group showed a significant difference (P < 0.05) with the one in the "nonresponding" group. The SVM classifier with Quadratic kernel based on SFFS-selected features showed the best prediction performance (accuracy: 96.67%, sensitivity: 100%, specificity: 93.75%, average area under curve [AUC]: 0.8925) comparing with linear kernel (accuracy: 80.00%, sensitivity: 85.71%, specificity: 75.00%, average AUC: 0.7825), polynomial kernel (accuracy: 93.33%, sensitivity: 92.86%, specificity: 93.75%, average AUC: 0.9675), and radial basis function (RBF) kernel (accuracy: 86.67%, sensitivity: 85.71%, specificity: 87.50%, average AUC: 0.7900).

CONCLUSION

The use of SVM-based classifier of SEMG topography can be applied to identify the patient responding to functional restoration rehabilitation, which will help the healthcare worker to improve the efficiency of LBP rehabilitation.

LEVEL OF EVIDENCE

3.

Severity of back pain may influence choice and order of practitioner consultations across conventional, allied and complementary health care: a cross-sectional study of 1851 mid-age Australian women

BACKGROUND

Back pain is a common, disabling and costly disorder for which patients often consult with a wide range of health practitioners. Unfortunately, no research to date has directly examined the association between the severity of back pain and back pain sufferers' choice of whom and in what order to consult different health practitioners.

METHODS

This is a sub-study of the large nationally representative Australian Longitudinal Study on Women's Health (ALSWH). The mid-age cohort women (born 1946-51, n = 13,715) of the ALSWH were recruited from the Australian national Medicare database in 1996. These women have been surveyed six time, with survey 6 being conducted in 2010 (n = 10,011). Mid-age women (n = 1851) who in 2010 had sought help from a health care practitioner for their back pain were mailed a self-report questionnaire targeting their previous 12 months of health services utilisation, health status and their levels of back pain intensity.

RESULTS

A total of 1620 women were deemed eligible and 1310 (80.9 %) returned completed questionnaires. Mid-age women with back pain visited various conventional, allied health and CAM practitioners for care: 75.6 % consulted a CAM practitioner; 58.4 % consulted a medical doctor; and 54.2 % consulted an allied health practitioner. Women with the most severe back pain sought conventional care from a general practitioner, and those who consulted a general practitioner first had more severe back pain than those who consulted another practitioner first. Following the general practitioner visit, the women with more severe back pain were more likely to be referred to a conventional specialist, and those with less severe back pain were more likely to be referred to a physiotherapist.

CONCLUSIONS

Our findings suggest that women with more severe back pain are likely to visit a conventional practitioner first, whereas women with less severe back pain are likely to explore a range of treatment options including CAM practitioners. The improvement of back pain over time following the various possible sequencing of consultations with different types of health practitioners is a topic with implications for ensuring safe and effective back pain care and worthy of further detailed investigation.

Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis

Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Ten electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP.

PERSPECTIVE

In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions.

What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies

OBJECTIVES

The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain.

METHODS

Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis.

RESULTS

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.

DISCUSSION

People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials

There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE(®) , Cochrane, Web of Science, SciELO and EMBASE(™) electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate-to-high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance.

Introducing Acceptance and Commitment Therapy to a physiotherapy-led pain rehabilitation programme: an Action Research study

BACKGROUND

Recent developments in pain rehabilitation emphasise the importance of promoting psychological flexibility. Acceptance and Commitment Therapy (ACT) is one approach that has been shown to be effective for the treatment of chronic musculoskeletal pain. However, studies have shown that introducing innovative approaches such as ACT into established health care can cause some anxiety for professional groups. We used Action Research to evaluate the implementation of ACT to a physiotherapy-led pain rehabilitation programme.

METHODS

All staff in the pain service were invited to participate. Participants took part in focus groups, engaged in reflective sessions/meetings and completed reflective diaries. The analysis was undertaken by an experienced qualitative researcher using constant comparison. Participants reviewed emerging themes and validated the findings.

RESULTS

Four key themes emerged from the study: (a) the need to see pain as an embodied, rather than dualistic, experience; (b) the need for a more therapeutic construction of 'acceptance'; (c) value-based goals as profound motivation for positive change; and (d) it's quite a long way from physiotherapy. Integral to a therapeutic definition of acceptance was the challenge of moving away from 'fixing' towards 'sitting with'. Participants described this as uncomfortable because it did not fit their biomedical training.

CONCLUSION

This article describes how Action Research methodology was used in the introduction of ACT to a physiotherapy-led pain rehabilitation programme. The innovation of this study is that it helps us to understand the potential barriers and facilitators to embedding an ACT philosophy within a physiotherapy setting.

Complexity in the physiotherapy management of low back disorders: clinical and research implications

Over the past decade a wide variety of approaches for the management of low back disorders (LBD) have been developed and evaluated in clinical trials. As a consequence physiotherapists and researchers interested in LBD are faced with a range of issues to do with complexity. These issues will be explored and suggestions made to improve the delivery of high quality research evidence and better patient outcomes.