Clinical challenges of classification based targeted therapies for non-specific low back pain: What do physiotherapy practitioners and managers think?

The perceptions of individuals with musculoskeletal disorders towards prognosis: An exploratory qualitative study

QUESTION(S)

How do individuals living with musculoskeletal disorders perceive the concept of prognosis?

DESIGN

Exploratory phenomenological study.

PARTICIPANTS

Individuals aged 18 years or older currently experiencing a musculoskeletal disorder.

DATA ANALYSIS

Single semi-structured one-on-one interviews were conducted. Data was analysed using inductive coding and thematic analysis.

RESULTS

Five themes were identified. First, participants defined prognosis as the likely outcome associated with their diagnosis. Their prognosis was often associated with outcomes related to pain, tissue health, and function. Second, participants perceived pain as having a negative impact on their prognosis by limiting their function and having a psychological impact. Third, participants held biomedical views in that tissue health was perceived as a cause for their pain and that tissue healing was essential for pain cessation. It was also difficult for participants to distinguish between pain related to tissue damage, and pain that was not. Fourth, participants use their ability to complete leisure and functional activities to determine the success of their recovery. Finally, participants perceived receiving individual prognoses for pain, tissue health, and function that may be simultaneously occurring as both important and beneficial.

CONCLUSION

Overall, participants viewed receiving prognostic information as important and beneficial. When constructing their views on prognosis participants perceived that pain, tissue health, and functional ability could all impact upon prognosis, whilst having a prognosis of their own. Physiotherapists should consider conceptualising and discussing prognosis in terms of pain, tissue health, and function when managing musculoskeletal disorders.

Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background

Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors.

Methods

Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis.

Results

Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences).

Conclusions

Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice.

Identifying non-specific low back pain clinical subgroups from sitting and standing repositioning posture tasks using a novel Cardiff Dempster-Shafer Theory Classifier

BACKGROUND

Low back pain (LBP) classification systems are used to deliver targeted treatments matched to an individual profile, however, distinguishing between different subsets of LBP remains a clinical challenge.

METHODS

A novel application of the Cardiff Dempster-Shafer Theory Classifier was employed to identify clinical subgroups of LBP on the basis of repositioning accuracy for subjects performing a sitting and standing posture task. 87 LBP subjects, clinically subclassified into flexion (n = 50), passive extension (n = 14), and active extension (n = 23) motor control impairment subgroups and 31 subjects with no LBP were recruited. Thoracic, lumbar and pelvic repositioning errors were quantified. The Classifier then transformed the error variables from each subject into a set of three belief values: (i) consistent with no LBP, (ii) consistent with LBP, (iii) indicating either LBP or no LBP.

FINDINGS

In discriminating LBP from no LBP the Classifier accuracy was 96.61%. From no-LBP, subsets of flexion LBP, active extension and passive extension achieved 93.83, 98.15% and 97.62% accuracy, respectively. Classification accuracies of 96.8%, 87.7% and 70.27% were found when discriminating flexion from passive extension, flexion from active extension and active from passive extension subsets, respectively. Sitting lumbar error magnitude best discriminated LBP from no LBP (92.4% accuracy) and the flexion subset from no-LBP (90.1% accuracy). Standing lumbar error best discriminated active and passive extension from no LBP (94.4% and 95.2% accuracy, respectively).

INTERPRETATION

Using repositioning accuracy, the Cardiff Dempster-Shafer Theory Classifier distinguishes between subsets of LBP and could assist decision making for targeted exercise in LBP management.

"Selling" chronic pain: physiotherapists' lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients

Introduction: Chronic nonspecific lower back pain (CNSLBP) is a common musculoskeletal condition which can be a source of significant distress and disability for patients. Approaches to managing CNSLBP have been explored in healthcare literature, as has the importance of communication in physiotherapy practice. However, no previous studies have explored clinicians' experiences of communicating their understanding of this diagnosis to their patients.Methods: A qualitative research design, using hermeneutic phenomenological methodology, was employed. Five participants were purposively recruited for the research and data collected via semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Emergent, super-ordinate and master themes were developed to help convey the qualitative significant meanings of the lived-through experiences.Findings: Three master themes were identified, with each comprising two sub-themes. These were: 1) Patient-centeredness (1a. Understanding the patient; and 1b. emotional awareness and adaptability); 2) Getting patients "on board" (2a. the "selling" process; and 2b. paternalism and the clinician's perspective); and 3) Dealing with conflict and uncertainty (3a. fear of interpersonal conflict; and 3b. personal doubts and uncertainty).Conclusions: Personal conflicts were identified between clinicians' descriptions of their wishes to "sell" their own perspectives to patients while simultaneously wanting to demonstrate a patient-focused approach and avoid the interpersonal conflicts which arose from clashes with patients' beliefs. Building a good initial rapport, showing empathy and adapting approaches in response to perceptions of patients' reactions were perceived as strategies to help mitigate the risks of failed communication, but this was something for which participants felt unprepared by their prior training.

An international survey of the comprehensiveness of the McKenzie classification system and the proportions of classifications and directional preferences in patients with spinal pain

BACKGROUND

Classification of spinal pain has been a key goal identified in the research. However it is not clear if existing classification systems are comprehensive.

OBJECTIVE

To examine the comprehensiveness and distribution of classifications within the McKenzie classification system (MDT), and the directional preference in consecutive patients with spine pain.

STUDY DESIGN

Prospective, observational study.

METHODS

Clinicians with a Diploma in MDT provided data on patients that they had assessed, classified, managed, and then confirmed their classification at discharge. They provided data on the spinal area, the MDT classification, and the loading strategy used in management.

RESULTS

Fifty-four clinicians from at least 15 different countries provided data on 750 patients: lumbar 64.8%, cervical 29.6%, thoracic 5.6%. The distribution of classifications was as follows: Derangement 75.4%, OTHER 22.8%, Dysfunction 1.7%, Postural syndrome 0.1%. In Derangements 82.5% had a directional preference for extension, 12.9% for lateral forces, and 4.6% for flexion. Those patients classified as one of the OTHER subgroups were given specific classifications.

CONCLUSION

Derangement was the most common classification and extension was by far the most common directional preference. A substantial proportion were classified as OTHER subgroups, for whom management is less straightforward.

Fascial manipulation vs. standard physical therapy practice for low back pain diagnoses: A pragmatic study

BACKGROUND

Connective tissue mobility alters motor unit recruitment, but the restoration of fascial mobility allows for optimal motor function. The Fascial Manipulation^® (FM^®) method is a multiplanar approach that assesses and treats the mobility of deep fascia in specific anatomical locations where motor units converge.

OBJECTIVES

To assess the effects of FM^® vs. standard physical therapy treatment (SPT) in patients with low back pain (LBP).

DESIGN

Six-months controlled clinical trial.

METHOD

102 participants with LBP received SPT or FM^®. Numeric Pain Rating Scale (NPRS), 15- point Global Rating of Change (GROC), and Oswestry Disability Index (ODI) were used to monitor progress.

RESULTS

The FM^® group had a significantly lower ODI (p < 0.009) and NPS scores (p < 0.0001) and significantly higher GROC scores (p < 0.003) once their means were adjusted for initial scores. When comparing the SPT to FM^®, the final ODI decreased by at least 1 category in 48.9% of the SPT cases, while in 36.2% of the cases was no change. ODI minimal clinical importance difference (MCID) change of 10% decrease in scores occurred in 70.2% of the SPT group compared to 96% of the FM^® group (p = 0.003). ODI MCID change of 50% decrease in scores occurred in 40% of the SPT group compared to 64.6% of the FM^® group (p = 0.02) 44.7% of the participants in the SPT group had final GROC values above +5 at discharge, compared to 92% of the participants from the FM^® group (p = 0.0001). The FM^® subjects had almost three times the change in NPRS compared to SPT counterparts (-4.3 ± 2.2 to -1.5  ± 2.4, p=0.0001).

CONCLUSIONS

FM^® appears to improve NPRS, GROC, and ODI more than SPT. FM^® may provide an effective treatment technique for LBP.

A preliminary analysis of outcomes and end range procedures used to achieve centralization in people with low back pain

OBJECTIVES

To investigate the relationship between clinical outcome and the types of end range procedures used to achieve centralization in a sample of patients with low back pain (LBP) and/or peripheral symptoms.

METHODS

Small sample retrospective analysis of an observational cohort. Patients with LBP who centralized during initial visit at two physical therapy clinics were recruited to participate. The types of end range procedures used to achieve centralization were documented during each office visit and a chart review was performed after 4 weeks. Outcomes were determined by improvement in the Oswestry Disability Index (ODI) score after 4 weeks. Statistical analysis determined the association between the types of end range procedures and outcomes.

RESULTS

Thirty-one patients gave consent to participate. Nineteen patients met inclusion criteria and were included in data analysis. After 4 weeks, the improvement in mean ODI scores was 15.89 ± 16.28. Differing end range procedures were used to achieve centralization within this cohort. The types of end range procedures used to achieve centralization were not significantly associated with outcomes.

DISCUSSION

The results observed in this study promote exhausting many different types of end range procedures to determine if centralization can be achieved. Limiting the end range procedures used to assess centralization may fail to identify patients who can achieve centralization and subsequently have positive clinical outcomes. Larger cohort studies investigating relationships between outcomes and the types of end range procedures used to achieve centralization would contribute to management of people with LBP.

LEVEL OF EVIDENCE

4.

Experiences of Rehabilitation Professionals with the Implementation of a Back School for Patients with Chronic Low Back Pain: A Qualitative Study

A standardized curriculum back school (CBS) has been recommended for further dissemination in medical rehabilitation in Germany. However, implementation of self-management education programs into practice is challenging. In low back pain care, individual factors of professionals could be decisive regarding implementation fidelity. The study aim was to explore attitudes and experiences of professionals who conducted the back school. Qualitative interviews were led with 45 rehabilitation professionals. The data were examined using thematic analysis. Three central themes were identified: (a) “back school as a common thread,” (b) “theory versus practice,” and (c) “participation and patient-centeredness.” The CBS and its manual were frequently described positively because they provide structure. However, specified time was mentioned critically and there were heterogeneous perceptions regarding flexibility in conducting the CBS. Theory and practice in the CBS were discussed concerning amount, distribution, and conjunction. Participation and patient-centeredness were mainly mentioned in terms of amount and heterogeneity of participation as well as the demand for competences of professionals. Factors were detected that may either positively or negatively influence the implementation fidelity of self-management education programs. The results are explorative and provide potential explanatory mechanisms for behavior and acceptance of rehabilitation professionals regarding the implementation of biopsychosocial back schools.