Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092)

The Unseen Strain: Investigating the Awareness of Rhinoplasty Surgeons Regarding Their Spine Health

BACKGROUND

Musculoskeletal pain is a common occupational health problem among surgeons that can affect work productivity and quality of life.

OBJECTIVES

The aim of the study was to investigate the prevalence and causes of back pain among rhinoplasty surgeons, evaluate their routine practice, and identify unique risk factors. A further goal was to measure functional disabilities with the Total Disability Index (TDI) questionnaire.

METHODS

A structured online questionnaire was distributed to plastic surgeons performing rhinoplasty internationally. The questionnaire comprised sections on biodata, routine practice posture, length of practice, surgical duration, and the history of surgery or hospitalization related to these issues. In the second part of the survey, participants were asked to complete the TDI questionnaire.

RESULTS

The prevalence of back pain was reported by 93.6% of surgeons, with low back pain being the most common (76.7%). The average pain intensity for low back pain was 44.8 ± 26.8. The mean TDI score was calculated as 31 ± 12.1, with 58.2% of surgeons experiencing mild to moderate disability. Significant associations were found between musculoskeletal pain severity and disability index and factors such as BMI, exercise, years of rhinoplasty practice, number of surgeries performed per week, and average procedure length. Interestingly, only 16.4% of rhinoplasty surgeons had previous ergonomic training or education.

CONCLUSIONS

Musculoskeletal issues related to the spine are prevalent among rhinoplasty surgeons. It is imperative to educate surgeons about this underestimated health problem, provide proper physical rehabilitation targeting ergonomic concerns, and make changes to current practices to address this issue effectively.

LEVEL OF EVIDENCE: 5

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]

INTRODUCTION

Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP.

OBJECTIVE

The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial.

METHODS

A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered.

CONCLUSION

The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Measuring objective physical activity in people with chronic low back pain using accelerometers: a scoping review

Purpose

Accelerometers can be used to objectively measure physical activity. They could be offered to people with chronic low back pain (CLBP) who are encouraged to maintain an active lifestyle. The aim of this study was to examine the use of accelerometers in studies of people with CLBP and to synthesize the main results regarding the measurement of objective physical activity.

Methods

A scoping review was conducted following Arksey and O'Malley's framework. Relevant studies were collected from 4 electronic databases (PubMed, Embase, CINHAL, Web of Science) between January 2000 and July 2023. Two reviewers independently screened all studies and extracted data.

Results

40 publications out of 810 citations were included for analysis. The use of accelerometers in people with CLBP differed across studies; the duration of measurement, physical activity outcomes and models varied, and several limitations of accelerometry were reported. The main results of objective physical activity measures varied and were sometimes contradictory. Thus, they question the validity of measurement methods and provide the opportunity to discuss the objective physical activity of people with CLBP.

Conclusions

Accelerometers have the potential to monitor physical performance in people with CLBP; however, important technical limitations must be overcome.

The effectiveness of different aerobic exercises to improve pain intensity and disability in chronic low back pain patients: a systematic review

Background: Physical activity, including aerobic exercise, is highly recommended for chronic low back pain (CLBP) patients to improve pain intensity and functional disability. Objectives: To assess the effectiveness of different aerobic exercises to reduce pain intensity and functional disability in patients with CLBP. Methods: A computer-aided search was performed to find Randomised Controlled Trials (RCTs) that evaluated the effectiveness of different aerobic exercises in CLBP. Articles published between January 2007 to December 2020 were included in the review. Quality assessment using the PEDro scale, extraction of relevant information, and evaluation of outcomes were done by two reviewers independently. Results: A total of 17 studies were included that involved 1146 participants. Outcomes suggested that aerobic exercise combined with other interventions was more effective than aerobic exercise alone. Aerobic exercise with higher frequency (≥ 5 days/week) and longer duration (≥ 12 weeks) were effective to gain clinically significant (≥ 30%) improvements. Environment and using pedometer did not seem to influence the outcomes. Conclusions: Pain intensity and functional disability in CLBP patients can be minimized by prescribing aerobic exercise. However, to get better improvements, aerobic exercise should be done in combination with other interventions and at optimum frequency and duration. Further studies should emphasize examining the optimal doses and duration of different aerobic exercises.

Effect of integrated exercise therapy and psychosocial interventions on self-efficacy in patients with chronic low back pain: A systematic review

OBJECTIVE

Investigate if integrated exercise and psychosocial (EP) interventions effect self-efficacy to manage pain and self-efficacy for physical functioning compared to alternate interventions, usual care, waitlists and attention controls for individuals with chronic low back pain (CLBP).

METHODS

MEDLINE, Embase, CINAHL, Web of Science, PsychINFO, PEDro, and Cochrane Library were searched. Included randomized controlled trials utilized an EP intervention for CLBP and measured self-efficacy. Independent reviewers screened abstracts, reviewed full-texts, extracted data, and assessed risk of bias. GRADE, synthesis without meta-analysis, and ranges of effects (Hedges' g) were used.

RESULTS

2207 Participants were included (22-studies). EP interventions positively effected self-efficacy to manage pain short-term compared to usual care (range of effects: -0.02, 0.94) and controls (range of effects: 0.69, 0.80) and intermediately compared to usual care (range of effects: 0.11, 0.29); however, no differences were found when compared to alternate interventions. EP interventions positively effected self-efficacy for physical functioning short-term compared to alternate interventions (range of effects: 0.57, 0.71), usual care (range of effects: -0.15, 0.94), and controls (range of effects: 0.31, 0.56), and intermediately compared to alternate interventions (1-study, effect: 0.57) and controls (1-study, effect: 0.56). Conclusions were limited by low to very low-quality-evidence often from risk of bias, imprecision, and clinical/statistical heterogeneity.

CONCLUSIONS

EP interventions may be more effective short-term for self-efficacy to manage pain than usual care and waitlists, but not alternate interventions. EP interventions may be effective for self-efficacy for physical functioning at short- and intermediate-term compared to alternate interventions, usual care, waitlist and attention controls. Considerations for future research include methods for blinding and measurement of self-efficacy for physical functioning.

Impact on productivity impairment of a digital care program for chronic low back pain: A prospective longitudinal cohort study

BACKGROUND

Low back pain (LBP) is the leading cause of disability in the United States and the main reason for absenteeism. Successful management of chronic LBP (CLBP) is dependent on multimodal evidence-based interventions. Digital interventions (DI) may ease accessibility to such treatments, increasing adherence, while reducing healthcare-related costs.

OBJECTIVES

Assess the impact of a completely remote multimodal DI on productivity impairment in a real-work context cohort of patients with CLBP.

DESIGN

Longitudinal study.

METHODS

Ad-hoc analysis of an interventional, single-arm study of individuals with CLBP undergoing a DI for 12 weeks. Outcomes included the mean change in work productivity and activity impairment (including overall and non-work related activities), pain, depression, anxiety, fear-avoidance beliefs, analgesic usage, and engagement. Minimal clinically important change (MCIC) was calculated for productivity using anchor- and distribution-based methods.

RESULTS

From 560 patients at program start, 78.4% completed the DI. A significant improvement in overall productivity (20.21, 95%CI: 16.48-23.94) and in non-work related activities (21.36, 95%CI: 17.49-25.22) was observed, corresponding to a responder rate of 57.1-83.3% and 60.5-79.8%, respectively, and depending on the MCIC method. Significant improvements were reported for pain (2.32 points, 95%CI: 2.02-2.61), anxiety (5.24, 95%CI: 4.18-6.29), depression (6.38, 95%CI: 4.78-7.98) and fear-avoidance beliefs (8.11, 95%CI: 6.20-10.02). Both engagement (sessions per week) and patient satisfaction scores were high, 2.9 (SD 1.0) and 8.8/10 (SD 1.6), respectively.

CONCLUSIONS

This study demonstrated the utility of a multimodal DI to address productivity impairment. DIs have great potential to ease the burden of CLBP, providing an accessible and cost-effective modality of care.

TRIAL REGISTRATION

The study was approved by the New England IRB (protocol number 120190313) and prospectively registered in ClinicalTrials.gov, NCT04092946, on September 17th, 2019.

The facilitation of trunk muscles by abdominal bracing during walking in chronic low back pain patients

Walking is known to be beneficial for chronic low back pain (LBP) patients and fast walking recruits more trunk muscles. Abdominal bracing has also been shown to improve LBP and facilitate several trunk muscles. We aimed to investigate the effects of walking velocity and abdominal bracing on the activation of trunk muscles in chronic LBP patients during walking. Forty-six volunteers with chronic LBP underwent walking exercise on the treadmill without ("non-braced walking") and with abdominal bracing ("braced walking") at speeds of 4, 5, and 6 km/h, with the surface electrodes placed on their trunk muscles to measure muscle activity. The root mean square values of the surface electromyography amplitude data were obtained at the multifidus of lower (ML) and upper lumbar (MU), erector spinae of lower lumbar (EL) and thoracic (ET), rectus abdominis (RA), and external oblique (EO). All muscles activated significantly more at faster walking. The "braced walking" facilitated the ET and RA significantly more than the "non-braced walking". The interaction between the walking speed and abdominal bracing was significant at ML, MU, and RA. The increase in muscle activation observed at lower speed diminished as speed increased. Since "braced walking" seems to additionally facilitate the trunk muscles especially at slower gait speeds, patients who cannot walk fast may still be able to train their muscles by "braced walking."

Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach

Literature on current treatments for chronic low back pain (cLBP) were reviewed and 4 interventions were recommended for inclusion in a multisite cLBP clinical trial.

Introduction:

Objective:

Methods:

Conclusion:

Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis

OBJECTIVE

To determine which type of exercise is best for reducing pain and disability in adults with chronic low back pain (LBP).

DESIGN

Systematic review with a network meta-analysis (NMA) of randomized controlled trials (RCTs).

LITERATURE SEARCH

Six electronic databases were systematically searched from inception to July 2021.

STUDY SELECTION CRITERIA

RCTs testing the effects of exercise on reducing self-perceived pain or disability in adults (aged 18-65 years) with chronic LBP.

DATA SYNTHESIS

We followed the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, incorporating NMAs of health care interventions) statement when reporting our NMA. A frequentist NMA was conducted. The probability of each intervention being the most effective was conducted according to surface under the cumulative ranking curve (SUCRA) values.

RESULTS

We included 118 trials (9710 participants). There were 28 head-to-head comparisons, 7 indirect comparisons for pain, and 8 indirect comparisons for disability. Compared with control, all types of physical exercises were effective for improving pain and disability, except for stretching exercises (for reducing pain) and the McKenzie method (for reducing disability). The most effective interventions for reducing pain were Pilates, mind-body, and core-based exercises. The most effective interventions for reducing disability were Pilates, strength, and core-based exercises. On SUCRA analysis, Pilates had the highest likelihood for reducing pain (93%) and disability (98%).

CONCLUSION

Although most exercise interventions had benefits for managing pain and disability in chronic LBP, the most beneficial programs were those that included (1) at least 1 to 2 sessions per week of Pilates or strength exercises; (2) sessions of less than 60 minutes of core-based, strength, or mind-body exercises; and (3) training programs from 3 to 9 weeks of Pilates and core-based exercises. J Orthop Sports Phys Ther 2022;52(8):505-521. Epub: 19 June 2022. doi:10.2519/jospt.2022.10671.

The Effectiveness of Interventions and Intervention Components for Increasing Physical Activity and Reducing Sedentary Behaviour in People With Persistent Musculoskeletal Pain: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis investigated the effectiveness of physical activity (PA) and sedentary behavior (SB) interventions on PA and SB levels in people with persistent musculoskeletal pain. We explored the effectiveness of behavior change techniques (BCTs), the use of behavior change theory and non-PA/SB outcomes. Randomized controlled trials of PA or SB interventions for people with persistent musculoskeletal pain were eligible. Twenty-three studies were included. Quality of evidence was assessed using the GRADE approach. Meta-analysis demonstrated a small effect for PA post-intervention (Hedge's g = .321, CI .136-.507, P = .001, very low-quality evidence). There was no effect for longer-term follow-up PA (low quality evidence) or SB outcomes (very low-quality evidence). There was a small effect for studies with low risk-of-bias at longer-term follow-up PA. Self-report PA outcomes, PA and education interventions, non-self-selected PA, a combination of supervised and unsupervised PA and a combination of individual and group-based interventions had larger effects. Heterogeneity was moderate to considerable. Risk-of-bias, assessed using Cochrane risk-of-bias tool (version two), was generally low. Five promising BCTs were identified: "adding objects to the environment," "goal setting (outcome)," "action planning," "monitoring outcome(s) of behaviour by others without feedback" and "feedback on outcome(s) of behaviour." In conclusion, there is evidence for a modest benefit for PA interventions immediately post-intervention, however the quality of evidence is very low. There was no evidence for longer-term follow-up PA or SB. Higher quality studies of PA and SB interventions that use objective measures are needed. PROSPERO registration: CRD42020180260. PERSPECTIVE: This review investigated the effects of physical activity and sedentary behavior interventions on physical activity and sedentary behavior levels in people with persistent musculoskeletal pain. Current evidence shows a modest benefit for interventions on physical activity post-intervention but not at longer-term follow-up or on sedentary behavior at any time-point, however quality of evidence is low to very low.

Adding Physical Activity Coaching and an Activity Monitor Was No More Effective Than Adding an Attention Control Intervention to Group Exercise for Patients With Chronic Nonspecific Low Back Pain (PAyBACK Trial): A Randomized Trial

OBJECTIVE

To investigate whether adding physical activity coaching and an activity monitor enhanced the effects of a group exercise program on pain intensity and disability for people with chronic nonspecific low back pain.

DESIGN

Randomized controlled trial with concealed allocation, intention-to-treat analysis, and blinding of participants and assessors.

METHODS

One hundred sixty participants with chronic nonspecific low back pain who were aged between 18 and 60 years and seeking care at an outpatient physiotherapy clinic participated. Both groups received supervised group exercise therapy. The intervention group also received physical activity coaching sessions aimed at improving physical activity, and physical activity electronic feedback delivered by an activity monitor. The attention control group received modified approaches of coaching sessions and an activity monitor. Disability was measured using the Roland Morris Disability Questionnaire (0-24), and pain intensity was measured using the 11-point Numerical Rating Scale (0-10). Linear mixed models were performed to test for differences between groups.

RESULTS

There were no differences between groups for reductions in disability (mean difference [MD] = -0.5 out of 24 points; 95% confidence interval [CI]: -2.2, 1.1) and pain intensity (MD = -0.4 out of 10 points; 95% CI: -1.3, 0.5) at 3-month follow-up. There were no between-groups differences at 6- and 12-month follow-up assessments.

CONCLUSION

Adding targeted physical activity coaching and an activity monitor did not reduce pain intensity or disability more than an attention control approach in participants with chronic low back pain who were undertaking a group exercise program. J Orthop Sports Phys Ther 2022;52(5):287-299. doi:10.2519/jospt.2022.10874.

Walking, Cycling, and Swimming for Nonspecific Low Back Pain: A Systematic Review With Meta-analysis

OBJECTIVE

To investigate the effectiveness of walking/running, cycling, or swimming for treating or preventing nonspecific low back pain (LBP).

DESIGN

Intervention systematic review.

LITERATURE SEARCH

Five databases were searched to April 2021.

STUDY SELECTION CRITERIA

Randomized controlled trials evaluating walking/running, cycling, or swimming to treat or prevent LBP were included.

DATA SYNTHESIS

We calculated standardized mean differences (SMDs) and 95% confidence intervals (CIs). Certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

No trials assessed LBP prevention or addressed acute LBP. Nineteen trials (2362 participants) assessed treatment of chronic/recurrent LBP. Low-certainty evidence suggests that walking/running was less effective than alternate interventions in reducing pain in the short term (8 trials; SMD, 0.81; 95% CI: 0.28, 1.34) and medium term (5 trials; SMD, 0.80; 95% CI: 0.10, 1.49). High-certainty evidence suggests that walking/running was less effective than alternate interventions at reducing disability in the short term (8 trials; SMD, 0.22; 95% CI: 0.06, 0.38) and medium term (4 trials; SMD, 0.28; 95% CI: 0.05, 0.51). There was high-certainty evidence of a small effect in favor of walking/running compared to minimal/no intervention for reducing pain in the short term (10 trials; SMD, -0.23; 95% CI: -0.35, -0.10) and medium term (6 trials; SMD, -0.26; 95% CI: -0.40, -0.13) and disability in the short term (7 trials; SMD, -0.19; 95% CI: -0.33, -0.06). Scarcity of trials meant few conclusions could be drawn regarding cycling and swimming.

CONCLUSION

Although less effective than alternate interventions, walking/running was slightly more effective than minimal/no intervention for treating chronic/recurrent LBP. J Orthop Sports Phys Ther 2022;52(2):85-99. Epub 16 Nov 2021. doi:10.2519/jospt.2022.10612.

Novel walking pole gait pattern improves activity in an older adult with chronic low back pain

A 65-year-old woman with chronic low back pain participated in a 1-week community walking poles course. Although the participant received instruction in the standard Nordic walking method, she independently adopted a novel, modified, two-point gait pattern. Subsequently, her pain and activity tolerance using walking poles were monitored at 6 and 12 months. The participant ambulated two times the distance and reported lower ratings of perceived exertion and pain at 6-month and 12month follow-ups when walking with poles compared with walking without poles. This case highlights the potential effect of respecting patient preference within the clinical decision-making model. Doing so empowered a participant with chronic low back pain to adopt a novel, self-selected gait pattern and improve her short-term and long-term outcomes associated with chronic musculoskeletal disease.

Aerobic Physical Exercise for Pain Intensity, Aerobic Capacity, and Quality of Life in Patients With Chronic Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, chronic pain is a disabling condition that is difficult to manage, which generates a high burden on health systems. The objective is to determine the effects of aerobic physical exercise in adults with chronic pain.

METHODS

A systematic review of searches in databases including MEDLINE, LILACS, ScienceDirect, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar was conducted. The search process was carried out until July 31, 2020, and the study selection process was independently carried out through a criteria analysis for each phase. Outcome measures were chosen: aerobic capacity, physical function, quality of life, and pain.

RESULTS

Twenty-seven studies were included in which aerobic exercise was considered as an option to treat chronic pain. These studies showed significant results compared with other treatment options in terms of pain measurements (-0.22 [-0.42 to -0.03]) and aerobic capacity. For quality of life, there were significant improvements in the physical function component over the mental health component evaluated with the short form health survey-36/12.

CONCLUSION

Aerobic exercise is a nonpharmacological therapeutic option for treatment. Also, aerobic capacity and endurance improved when this type of exercise was prescribed, thus resulting in a substantial improvement in the quality of life of people suffering from chronic pain.

Examining the relationship between elderly patients' fear of falling after spinal surgery and pain, kinesiophobia, anxiety, depression and the associated factors

This study aimed to examine the relationship between fear of falling in elderly patients who underwent spinal surgery and pain, kinesiophobia, anxiety, depression, and associated factors. The study was a descriptive, cross-sectional design. The research sample consisted of 211 elderly patients who had undergone spinal surgery. The average age of the patients was 66.68 ± 5.57. Of the sample, 83.4% were afraid of falling, and 21.3% were severely afraid of falling. In the study, age (β = 0.115, p = 0.005), being a woman (β = -0.182, p < 0.001), pain (β = 0.269, p < 0.001), risk of falling (β = 0.084, p = 0.49), Hospital Anxiety and Depression Scale-Anxiety (HADS-A) (β = 0.135, p = 0.044), Hospital Anxiety and Depression Scale Anxiety-Depression (HADS-D) (β = 0.382, p < 0.001), and kinesiophobia (β = 0.722, p < 0.001) were statistically significant predictors of fear of falling. This study provided important information about the variables that surgical nurses should pay attention to while evaluating the fear of falling in elderly patients who underwent spinal surgery.

Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis

BACKGROUND

While chronic exercise training has been demonstrated to be an effective non-pharmacological treatment for chronic low back pain (CLBP), there has been a relative lack of evidence or clinical guidelines for whether a posterior chain resistance training programme provides any benefits over general exercise (GE).

OBJECTIVES

To determine if chronic posterior chain resistance training (PCRT), defined as exercise programmes of ≥6 weeks duration focused on the thoracic, lumbar and hip extensor musculature, is more effective than GE in improving pain, level of disability, muscular strength and the number of adverse events in recreationally active and sedentary individuals with CLBP.

METHODS

Four electronic databases were systematically searched from 25 September 2019 until 30 August 2020. Using the Joanna Briggs Institute (JBI) Critical Appraisal Tools checklist for randomized controlled trials (RCTs), articles were critically appraised and compared against the inclusion/exclusion criteria. Standardized mean difference (SMD), risk difference (RD) and confidence interval (CI) were calculated using Review Manager 5.3.

RESULTS

Eight articles were included, with a total of 408 participants (203 PCRT, 205 GE). Both PCRT and GE were effective in improving a number of CLBP-related outcomes, but these effects were often significantly greater in PCRT than GE, especially with greater training durations (i.e. 12-16 weeks compared to 6-8 weeks). Specifically, when compared to GE, PCRT demonstrated a greater reduction in pain (SMD = - 0.61 (95% CI - 1.21 to 0.00), p = 0.05; I2 = 74%) and level of disability (SMD = - 0.53 (95% CI - 0.97 to - 0.09), p = 0.02; I2 = 52%), as well as a greater increase in muscle strength (SMD = 0.67 (95% CI 0.21 to 1.13), p = 0.004; I2 = 0%). No differences in the number of adverse events were reported between PCRT and GE (RD = - 0.02 (95% CI - 0.10 to 0.05), p = 0.57; I2 = 72%).

CONCLUSION

Results of the meta-analysis indicated that 12-16 weeks of PCRT had a statistically significantly greater effect than GE on pain, level of disability and muscular strength, with no significant difference in the number of adverse events for recreationally active and sedentary patients with CLBP. Clinicians should strongly consider utilizing PCRT interventions for 12-16 weeks with patients with CLBP to maximize their improvements in pain, disability and muscle strength. Future research should focus on comparing the efficacy and adverse events associated with specific PCRT exercise training and movement patterns (i.e. deadlift, hip lift) in treating this population.

TRIAL REGISTRATION

PROSPERO CRD42020155700 .

Region-specific Exercises vs General Exercises in the Management of Spinal and Peripheral Musculoskeletal Disorders: A Systematic Review With Meta-analyses of Randomized Controlled Trials

OBJECTIVE

To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs).

DATA SOURCES

Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health.

STUDY SELECTION

Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs.

DATA EXTRACTION

Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310).

DATA SYNTHESIS

Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence.

CONCLUSIONS

The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain

Introduction

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective.

Methods

The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale.

Results

Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high.

Conclusion

We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain

BACKGROUND

Walking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice.

METHODS

Randomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate.

RESULTS

N = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks.

CONCLUSIONS

Overall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP.

TRIAL REGISTRATION

United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

The effect of pedometer-supported walking and telemonitoring after disc hernia surgery on pain and disability levels and quality of life

AIM

The aim of this study was to determine the effect of pedometer-supported walking and telemonitoring after lumbar disc hernia surgery on pain and disability levels and quality of life.

METHODS

This was a randomized controlled trial with two randomly selected groups conducted between March 2018 and January 2019. Sixty-seven participants (33 in the intervention group and 34 in the control group) who had undergone lumbar microdiscectomy were allocated to receive and not to receive walking exercise. Pain and disability levels and quality of life of groups were tested with the McGill Pain Questionnaire, the Oswestry Disability Index and the 36-Item Short Form Survey. Measurements were taken 3 weeks after surgery and following completion of the first, second and third months.

RESULTS

Compared with the control group, pain level at the first and second months and disability level at the second and third months in the intervention group were significantly lower (p < 0.05), and in the third month, subdimension scores of quality of life (the physical role difficulty, energy and vitality, mental health, social functionality and pain) were higher (p < 0.05).

CONCLUSIONS

Walking after herniated disc surgery decreased pain and disability levels and increased the quality of life; nurses can encourage adherence to walking as an effective intervention.

Comparing the effectiveness of group-based exercise to other non-pharmacological interventions for chronic low back pain: A systematic review

Background

Low back pain (LBP) is the leading cause of disability worldwide with a substantial financial burden on individuals and health care systems. To address this, clinical practice guidelines often recommend non-pharmacological, non-invasive management approaches. One management approach that has been recommended and widely implemented for chronic LBP is group-based exercise programs, however, their clinical value compared with other non-pharmacological interventions has not been investigated systematically.

Objective

To compare the effectiveness of group-based exercise with other non-pharmacological interventions in people with chronic LBP.

Methods

Four electronic databases were searched by two independent reviewers. Only randomized controlled trials that compared group-based exercise with other non-pharmacological interventions for chronic LBP were eligible. Study quality was assessed using the Cochrane Handbook for systematic reviews of Interventions by two independent reviewers.

Results

Eleven studies were eligible. We identified strong evidence of no difference between group exercise and other non-pharmacologic interventions for disability level and pain scores 3-month post-intervention in people with chronic LBP. We could not find any strong or moderate evidence for or against the use of group-based exercise in the rehabilitation of people with chronic LBP for other time-points and health measurement outcomes. We found no statistically significant differences in disability and quality of life and pain between the group and individual non-pharmacological interventions that included exercise.

Conclusion

With this equivocal finding, group-based exercise may be a preferred choice given potential advantages in other domains not reviewed here such as motivation and cost. Further research in this area is needed to evaluate this possibility.

The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019.

STUDY SELECTION CRITERIA

We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders.

DATA SYNTHESIS

We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses.

RESULTS

Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions.

CONCLUSION

Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care. J Orthop Sports Phys Ther 2020;50(11):597-606. doi:10.2519/jospt.2020.9666.

Effectiveness and cost-effectiveness of a progressive, individualised walking and education programme for prevention of low back pain recurrence in adults: study protocol for the WalkBack randomised controlled trial

INTRODUCTION

Low back pain (LBP) is recognised globally as a prevalent, costly and disabling condition. Recurrences are common and contribute to much of the burden of LBP. Current evidence favours exercise and education for prevention of LBP recurrence, but an optimal intervention has not yet been established. Walking is a simple, widely accessible, low-cost intervention that has yet to be evaluated. This randomised controlled trial (RCT) aims to establish the effectiveness and cost-effectiveness of a progressive and individualised walking and education programme (intervention) for the prevention of LBP recurrences in adults compared with no treatment (control).

METHODS AND ANALYSIS

A pragmatic, two-armed RCT comparing walking and education (n=349) with a no treatment control group (n=349). Inclusion criteria are adults recovered from an episode of non-specific LBP within the last 6 months. Those allocated to the intervention group will receive six sessions (three face to face and three telephone delivered) with a trained physiotherapist to facilitate a progressive walking programme and education over a 6-month period. The primary outcome will be days to first recurrence of an episode of activity-limiting LBP. The secondary outcomes include days to recurrence of an episode of LBP, days to recurrence of an episode of LBP leading to care seeking, disability and quality of life measured at 3, 6, 9 and 12 months and costs associated with LBP recurrence. All participants will be followed up monthly for a minimum of 12 months. The primary intention-to-treat analysis will assess difference in survival curves (days to recurrence) using the log-rank statistic. The cost-effectiveness analysis will be conducted from the societal perspective.

ETHICS AND DISSEMINATION

Approved by Macquarie University Human Research Ethics Committee (Reference: 5201949218164, May 2019). Findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12619001134112.

Feasibility cluster randomised controlled trial evaluating a theory-driven group-based complex intervention versus usual physiotherapy to support self-management of osteoarthritis and low back pain (SOLAS)

BACKGROUND

The self-management of osteoarthritis (OA) and low back pain (LBP) through activity and skills (SOLAS) theory-driven group-based complex intervention was developed primarily for the evaluation of its acceptability to patients and physiotherapists and the feasibility of trial procedures, to inform the potential for a definitive trial.

METHODS

This assessor-blinded multicentre two-arm parallel cluster randomised controlled feasibility trial compared the SOLAS intervention to usual individual physiotherapy (UP; pragmatic control group). Patients with OA of the hip, knee, lumbar spine and/or chronic LBP were recruited in primary care physiotherapy clinics (i.e. clusters) in Dublin, Ireland, between September 2014 and November 2015. The primary feasibility objectives were evaluated using quantitative methods and individual telephone interviews with purposive samples of participants and physiotherapists. A range of secondary outcomes were collected at baseline, 6 weeks (behaviour change only), 2 months and 6 months to explore the preliminary effects of the intervention. Analysis was by intention-to-treat according to participants' cluster allocation and involved descriptive analysis of the quantitative data and inductive thematic analysis of the qualitative interviews. A linear mixed model was used to contrast change over time in participant secondary outcomes between treatment arms, while adjusting for study waves and clusters.

RESULTS

Fourteen clusters were recruited (7 per trial arm), each cluster participated in two waves of recruitment, with the average cluster size below the target of six participants (intervention: mean (SD) = 4.92 (1.31), range 2-7; UP: mean (SD) = 5.08 (2.43), range 1-9). One hundred twenty participants (83.3% of n = 144 expected) were recruited (intervention n = 59; UP n = 61), with follow-up data obtained from 80.8% (n = 97) at 6 weeks, 84.2% (n = 101) at 2 months and 71.7% (n = 86) at 6 months. Most participants received treatment as allocated (intervention n = 49; UP n = 54). The qualitative interviews (12 participants; 10 physiotherapists (PTs) found the intervention and trial procedures acceptable and appropriate, with minimal feasible adaptations required. Linear mixed methods showed improvements in most secondary outcomes at 2 and 6 months with small between-group effects.

CONCLUSIONS

While the SOLAS intervention and trial procedures were acceptable to participants and PTs, the recruitment of enough participants is the biggest obstacle to a definitive trial.

TRIAL REGISTRATION

ISRCTN ISRCTN49875385 . Registered on 26 March 2014.

The effects of walking intervention on preventing neck pain in office workers: A randomized controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy of increased daily walking steps on the 6-month incidence of neck pain among office workers.

METHODS

Healthy office workers with high risk of neck pain were recruited into a 6-month prospective cluster-randomized controlled trial. Participants were randomly assigned at the cluster level, into either intervention (n = 50) or control (n = 41) groups. Participants in the intervention group were instructed to increase their daily walking steps to a designated level for a duration of 6 months. Participants in the control group received no intervention. The outcome measures included the 6-month incidence of neck pain as well as its pain intensity and disability level. Analyses were performed using multivariable logistic regression model.

RESULTS

Of the participants in the intervention and control groups, 22% and 34% reported a 6-month incidence of neck pain, respectively. After adjusting for confounders, a significant preventive effect of walking intervention was found (adjusted odd ratio 0.22, 95% confidence interval 0.06-0.75). No significant difference in pain intensity and disability level was found between those in the intervention and control groups.

CONCLUSION

An intervention to increase daily walking steps reduced onset neck pain in high-risk office workers. However, the walking interventions did not decrease pain intensity and disability in those increasing the number of daily walking steps compared to the control group.

Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review

OBJECTIVE

To systematically review and critically appraise the effectiveness of conservative and surgical interventions to reduce fear in studies of people with chronic low back pain, based on the analysis of randomized controlled trials for which fear was a primary or secondary outcome.

DATA SOURCES

Electronic databases PubMed, CINAHL, PsycINFO, PEDro, and CENTRAL, as well as manual searches and grey literature were searched from inception until May 2019.

STUDY SELECTION

Randomized controlled trials analyzing the effectiveness of conservative and surgical interventions to reduce fear were included.

DATA EXTRACTION

Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and quality of the evidence judgment.

DATA SYNTHESIS

Sixty-one studies (n=7201) were included. A large number of fear-related search terms were used but only 3 fear constructs (kinesiophobia, fear-avoidance beliefs, fear of falling) were measured in the included studies. Multidisciplinary and psychological interventions as well as exercise reduced kinesiophobia. Fear-avoidance beliefs were reduced by the aforementioned interventions, manual therapy, and electrotherapy. A multidisciplinary intervention reduced the fear of falling. There was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia. There was moderate evidence of manual therapy and electrotherapy to reduce fear-avoidance beliefs.

CONCLUSIONS

The present systematic review highlights the potential effectiveness of conservative interventions to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain. This information can help health professionals to reduce fear when treating patients with this condition.

Abstracts of low back pain trials are poorly reported, contain spin of information and are inconsistent with the full text: An overview study

OBJECTIVE

To investigate trials abstracts evaluating treatments for low back pain with regards to completeness of reporting, spin (i.e., interpretation of study results that overemphasizes the beneficial effects of the intervention), and inconsistencies in data with the full text.

DATA SOURCES

The search was performed on Physiotherapy Evidence Database (PEDro) in February 2016.

STUDY SELECTION

This is an overview study of a random sample of 200 low back pain trials published between 2010 and 2015. The languages of publication were restricted to English, Spanish and Portuguese.

DATA EXTRACTION

Completeness of reporting was assessed using the CONSORT for Abstracts checklist (CONSORT-A). Spin was assessed using a SPIN-checklist. Consistency between abstract and full text were assessed by applying the assessment tools to both the abstract and full text of each trial and calculating inconsistencies in the summary score (paired t test) and agreement in the classification of each item (Kappa statistics). Methodological quality was analyzed using the total PEDro score.

DATA SYNTHESIS

The mean number of fully reported items for abstracts using the CONSORT-A was 5.1 (SD 2.4) out of 15 points and the mean number of items with spin was 4.9 (SD 2.6) out of 7 points. Abstract and full text scores were statistically inconsistent (P=0.01). There was slight to moderate agreement between items of the CONSORT-A in the abstracts and full text (mean Kappa 0.20 SD 0.13) and fair to moderate agreement for items of the SPIN-checklist (mean Kappa 0.47 SD 0.09).

CONCLUSIONS

The abstracts were incomplete, with spin and inconsistent with the full text. We advise health care professionals to avoid making clinical decisions based solely upon abstracts. Journal editors, reviewers and authors are jointly responsible for improving abstracts, which could be guided by amended editorial policies.

The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial

BACKGROUND

Various exercises have been proposed to mitigate chronic low back pain (LBP). However, to date, no one particular exercise has been shown to be superior. Hence, the aim of this study was to compare the efficiency between 2 exercises: the individualized graded lumbar stabilization exercise (IGLSE) and walking exercise (WE).

METHODS

A randomized controlled trial was conducted in 48 participants with chronic LBP. After screening, participants were randomized to 1 of 4 groups: flexibility exercise, WE, stabilization exercise (SE), and stabilization with WE (SWE) groups. Participants underwent each exercise for 6 weeks. The primary outcome was visual analog scale (VAS) of LBP during rest and physical activity. Secondary outcomes were as follows: VAS of radiating pain measured during rest and physical activity; frequency of medication use (number of times/day); Oswestry disability index; Beck depression inventory; endurances of specific posture; and strength of lumbar extensor muscles.

RESULTS

LBP during physical activity was significantly decreased in all 4 groups. Exercise frequency was significantly increased in the SE and WE groups; exercise time was significantly increased in the SE group. The endurance of supine, side lying, and prone posture were significantly improved in the WE and SWE groups.

CONCLUSIONS

Lumbar SE and WE can be recommended for patients with chronic LBP because they not only relieve back pain but also prevent chronic back pain through improving muscle endurance.

Is occupational or leisure physical activity associated with low back pain? Insights from a cross-sectional study of 1059 participants

BACKGROUND

Low back pain is a highly prevalent and disabling musculoskeletal disorder. Physical activity is widely used as a prevention strategy for numerous musculoskeletal disorders; however, there is still conflicting evidence as to whether physical activity is a protective or risk factor for low back pain or whether activity levels differ between people with and without low back pain.

OBJECTIVE

To investigate the association between low back pain and different types (occupational and leisure) and intensities (moderate and vigorous) of physical activity.

METHODS

This is cross-sectional observational study. We included in this study a total of 1059 individuals recruited from a Spanish twin registry with data available on low back pain.

OUTCOME

Self-reported leisure and occupational physical activity were the explanatory variables. The low back pain outcome used in this study was recurrent low back pain.

RESULTS

Our results indicate that leisure physical activity is associated with a lower prevalence of recurrent low back pain. In contrast, occupational physical activity, such as carrying, lifting heavy weight while inclined, awkward postures (e.g. bending, twisting, squatting, and kneeling) are associated with a higher prevalence of recurrent low back pain. There was no statistically significant association between other occupational physical activities, such as sitting or standing, and low back pain.

CONCLUSION

Leisure and occupational physical activity are likely to have an opposed impact on low back pain. While leisure physical activity appears to be protective, occupational physical activity appears to be harmful to low back pain. Future longitudinal studies should assist in formulating guidelines addressing specific types and intensity of physical activity aimed at effectively preventing low back pain.

Walking more than 90minutes/week was associated with a lower risk of self-reported low back pain in persons over 50years of age: a cross-sectional study using the Korean National Health and Nutrition Examination Surveys

BACKGROUND CONTEXT

Physical activity, such as muscle strengthening and aerobic exercise, has been found to be effective for low back pain (LBP). However, the association between weekly walking duration and LBP in the general population remains poorly understood.

OBJECT

This study aimed (1) to analyze the association between walking and LBP and (2) to examine this association according to walking duration and overall walking days per week in a general population over 50years of age using a representative sample of Korean adults.

STUDY DESIGN

Cross-sectional study.

PATIENT SAMPLE

Data from the Korea National Health and Nutrition Examination Surveys V and VI, performed from 2010 to 2015.

OUTCOME MEASURES

Multiple logistic regression analysis was performed to determine the association between walking days and duration and LBP. Analysis was restricted to participants aged over 50years who responded to surveys on LBP and walking activity.

METHODS

National health and nutrition examination surveys were performed in the Korean general population (N=48,482) from 2010 to 2015. LBP status was surveyed using a self-reported questionnaire form ("Have you complained of LBP for more than 30days during the past 3 months?"). Daily walking activity (low-intensity activity) was evaluated using the following two questions: (1) "During the last 7days, on how many days did you walk for at least 10 minutes at a time? This includes at work and at home, walking to travel from place to place, and any other walking that you have done solely for recreation, sport, exercise, or leisure." (2) "How much time did you usually spend walking on each of those days?" Walking duration per day was classified into two categories: over 30min/day and over 1h/day. Overall walking days per week were categorized into <3, 3-4, and ≥5days/week. Basic characteristics, comorbidities, socioeconomic status, and other variables were used to create multiple logistic regression models. No sources of funding and no conflicts of interest were associated with this study.

RESULTS

Walking for more than 3days per week for over 30 minutes at a time was negatively associated with LBP in the unadjusted (adjusted odds ratio [aOR]: 0.65, p<.001) and fully adjusted logistic regression models (aOR: 0.79, p<.001). Similarly, walking for more than 5days per week for over 1 hour at a time was negatively associated with LBP in the unadjusted (aOR: 0.62, p<.001) and fully adjusted logistic regression models (aOR: 0.76, p<.001). The risk of LBP decreased with increasing walking days and duration.

CONCLUSIONS

Our study showed that longer walking duration was associated with a lower risk of LBP using a cross-sectional health survey in the Korean general population. Regular walking with a longer duration for more than 3days/week is significantly associated with a lower risk of LBP in the general population aged over 50years.

Use of Wearable Activity Trackers to Improve Physical Activity Behavior in Patients With Rheumatic and Musculoskeletal Diseases: A Systematic Review and Meta-Analysis

OBJECTIVE

Wearable activity trackers (WATs) could be a promising strategy to improve physical activity in patients with rheumatic and musculoskeletal diseases (RMDs). The aim was to assess the adherence to and effectiveness of WATs to increase physical activity levels in patients with RMDs.

METHODS

A systematic review was performed to identify all cohorts and controlled trials evaluating WATs in patients with RMDs, published between 2000 and 2018, by searching Medline, Embase, PsycINFO, and Cochrane. Data collected pertained to adherence, effectiveness on physical activity, or effectiveness on symptoms (pain, function, quality of life, or fatigue). Meta-analyses were performed with a random effects model.

RESULTS

Of 2,806 references, 17 studies were included, with a total of 1,588 patients: 8 studies (47%) in osteoarthritis, 5 (29%) in low-back pain, and 3 (18%) in inflammatory arthritis. Adherence assessed in 4 studies was high (weighted mean ± SD time worn was 92.7% ± 4.6%). A significant increase in physical activity was noted (mean difference 1,520 steps [95% confidence interval (95% CI) 580, 2,460], I² = 77%; or 16 minutes [95% CI 2, 29] of moderate-to-vigorous physical activity, I² = 0%). A significant increase in pain was found for long interventions (>8 weeks) (standardized mean difference 0.25 [95% CI 0.07, 0.43], I² = 0%).

CONCLUSION

WATs in patients with RMDs had a high short-term adherence, with a significant increase in the number of steps and time spent in moderate-to-vigorous physical activity, although pain should be monitored. WATs may be an effective option to increase physical activity in this at-risk population.

Integral movement therapy versus local movement therapy approach in patients with idiopathic chronic low-back pain: study protocol for a randomized controlled trial

BACKGROUND

Chronic low-back pain (CLBP) is one of the most common reasons for seeking medical care and it imposes a significant burden on individuals and society at large. Systematic reviews evaluating the effectiveness of supervised exercise therapies commonly conclude that, to date, there is no evidence to support the superiority of one form of exercise over another. Randomized controlled trials (RCT) to date included mostly trunk strengthening exercises (e.g. bird dog, plank) and there is no evidence about supervised, individually graded integral movement therapy program for patients with CLBP.

METHODS

The research design is a RCT with parallel-group design including two intervention groups: integral movement therapy and conventional local movement therapy. Participants in each group will receive 20 supervised sessions in a 10-week period, twice per week, for approximately 1 h per session. Outcome assessments will occur at baseline and immediately after intervention, follow-up will take place at six months and 12 months after the intervention. Prespecified analyses will evaluate the main effects of the treatment.

DISCUSSION

This trial will use a novel, previously unexplored integral approach to CLBP through exercises. In contrast to commonly used exercise programs, the integral program does not include specific local strength exercises for hip and trunk flexors and extensors. However, learning dynamic trunk muscle control in various body positions with added limb movements could be beneficial because of the parallels to everyday work. The study will contribute to clinical practice by providing evidence to guide professionals when deciding for the proper and efficient treatment of patients with CLBP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03623802 . Registered on 9th August 2018.

Behaviour change techniques applied in interventions to enhance physical activity adherence in patients with chronic musculoskeletal conditions: A systematic review and meta-analysis

OBJECTIVE

To identify Behaviour Change Techniques (BCTs) applied in interventions to enhance physical activity (PA) adherence in patients with chronic musculoskeletal conditions and to investigate the effectiveness of these interventions in increasing PA adherence.

METHODS

A systematic search of seven databases was conducted. We included (cluster/quasi-) randomised controlled trials comparing behaviour change interventions to no/placebo/minimal interventions or usual care and involving at least a three-month post-intervention follow-up. Methodological quality was assessed, study characteristics and BCTs were narratively summarised and a meta-analysis was conducted.

RESULTS

Across 22 included studies, we coded 8-18 BCTs (mean = 11.2) in intervention and 0-12 (mean = 3.5) in control groups. Common BCTs were "graded tasks", "goal setting", "self-monitoring", "problem solving" and "feedback". Meta-analyses of 17 studies revealed a small medium-term effect (3-6 months post-intervention, standardised mean difference (SMD) = 0.20, 95% CI 0.08-0.33) and no long-term effect (7-12 months post-intervention, SMD = 0.13, 95% CI -0.02 to 0.28). Subgroup analysis yielded a higher effect (SMD = 0.29, 95% CI 0.19-0.40) for interventions using a greater number of BCTs.

CONCLUSION

There is moderate quality evidence that interventions using BCTs are effective to enhance medium-term physical activity adherence.

PRACTICE IMPLICATION

While superiority of single BCTs was not shown, it is likely that using more BCTs results in better adherence.

Video-Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlledtable Trial (GAMEBACK)

BACKGROUND

Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP).

OBJECTIVE

The objective was to investigate the effects of home-based video game exercises on pain self-efficacy and care-seeking in older people with chronic LBP.

DESIGN

The study was a randomized controlled trial.

SETTING

The setting was a community and waiting list.

PARTICIPANTS

Sixty participants, aged > 55 years with chronic LBP, were randomized (1:1) to Wii Fit U exercises or to continue their usual activities for 8 weeks.

INTERVENTION

The intervention was home-based Wii Fit U flexibility, strengthening, and aerobic exercises for 60 minutes, 3 times per week, with fortnightly calls from a physical therapist.

MEASUREMENTS

Measurements included pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes).

RESULTS

The mean age of participants was 67.8 (standard deviation = 6.0) years. Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self-efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes.

LIMITATIONS

Participants and therapists were not blinded.

CONCLUSIONS

Wii Fit U exercises improved pain self-efficacy at 6 months, and pain and function immediately postintervention in older people with chronic LBP, but the clinical importance of these changes is questionable. Wii Fit U exercises had no effect on care-seeking, physical activity, disability, fear of movement/reinjury, or falls efficacy.

Variations of handheld loads increase the range of motion of the lumbar spine without compromising local dynamic stability during walking

BACKGROUND

Walking is often considered a beneficial management strategy for certain populations of low back pain patients. However, little is known about how simple challenges that people often encounter, such as carrying loads in the hands, affect the low back during walking.

RESEARCH QUESTION

How do variations in hand loading affect arm swing, lumbar spine range of motion (ROM), and lumbar spine local dynamic stability (LDS) during walking?

METHODS

Sixteen young healthy participants (8 female) performed nine treadmill walking trials, each at 1.25 m/s for 3 consecutive minutes. Conditions manipulated the magnitude of hand loads (unloaded, low, high) and location of hand loads (directly in hands, in bags). Kinematic markers were used to measure sagittal plane arm swing, 3D lumbar spine ROM, and lumbar spine LDS during each trial.

RESULTS

Arm swing was significantly (p < 0.001) reduced as load increased directly in the hands; however, when held in bags load magnitude had no effect. Further, arm swing was significantly (p < 0.0001) lower when loads were held in bags. Lumbar flexion/extension ROM was greatest with the low load compared to both unloaded (p = 0.012) and high load (p = 0.0717) conditions, and was also greater (p < 0.0001) with loads held directly in the hands compared to loads in bags. Despite these changes in lumbar spine ROM, lumbar spine LDS was not significantly affected by any of the variations in hand loading.

SIGNIFICANCE

The greater lumbar spine cyclic motion, elicited by low hand loads held directly in the hands during walking, may be beneficial to the health of the low back. No changes in lumbar LDS were found, thereby suggesting that the small, likely beneficial, increases in lumbar spine ROM are well controlled by the motor control system and do not create an increased risk of injury.

Physical activity and disability measures in chronic non-specific low back pain: a study of responsiveness

Objectives:

To compare the responsiveness of disability measures with physical activity measures in patients with chronic low back pain (CLBP) undergoing a course of physical therapy treatment.

Design:

This is a prospective cohort study with two-month follow-up.

Subjects:

A total of 106 patients presenting with non-specific CLBP of more than three months duration were recruited.

Main measures:

Disability measures investigated were Quebec Back Pain Disability Scale and Roland Morris Disability Questionnaire. Physical activity measures analyzed include the Baecke Habitual Physical Activity Questionnaire and objective measures derived from an accelerometer (i.e. total time spent in moderate-to-vigorous and light physical activity, number of steps and counts per minute). Disability and physical activity measures were collected at the baseline and after eight weeks of treatment. For the responsiveness analyses, effect size (ES) and standardized response mean (SRM) were calculated. Correlations between the change in disability and physical activity measures were calculated.

Results:

Responsiveness for disability measures was considered to be large with ESs ranging from −1.03 to −1.45 and SRMs ranging from −0.99 to −1.34, whereas all physical activity measures showed values lower than 0.20. Changes in disability measures did not correlate with changes in physical activity measures (correlation coefficients ranged from −0.10 to 0.09).

Conclusion:

Disability measures were responsive after a course of physical therapy treatment in patients with CLBP. The lack of responsiveness in the physical activity measures might be due to the inability of these measures to detect change over time or the use of an intervention not designed to increase physical activity levels.

Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis

OBJECTIVE

To investigate the cost-effectiveness of exercise therapy in the treatment of patients with non-specific neck pain and low back pain.

DESIGN

Systematic review of economic evaluations.

DATA SOURCES

The search was performed in 5 clinical and 3 economic electronic databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included economic evaluations performed alongside randomised controlled trials. Differences in costs and effects were pooled in a meta-analysis, if possible, and incremental cost-utility ratios (ICUR) were descriptively analysed.

RESULTS

Twenty-two studies were included. On average, exercise therapy was associated with lower costs and larger effects for quality-adjusted life-year (QALY) in comparison with usual care for subacute and chronic low back pain from a healthcare perspective (based on ICUR). Exercise therapy had similar costs and effect for QALY in comparison with other interventions for neck pain from a societal perspective, and subacute and chronic low back pain from a healthcare perspective. There was limited or inconsistent evidence on the cost-effectiveness of exercise therapy compared with usual care for neck pain and acute low back pain, other interventions for acute low back pain and different types of exercise therapy for neck pain and low back pain.

CONCLUSIONS

Exercise therapy seems to be cost-effective compared with usual care for subacute and chronic low back pain. Exercise therapy was not (more) cost-effective compared with other interventions for neck pain and low back pain. The cost-utility estimates are rather uncertain, indicating that more economic evaluations are needed.

REGISTRATION

PROSPERO, CRD42017059025.

The effects of walking intervention in patients with chronic low back pain: A meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this meta-analysis of randomized controlled trials was to gain insight into the effectiveness of walking intervention on pain, disability, and quality of life in patients with chronic low back pain (LBP) at post intervention and follow ups.

METHOD

Six electronic databases (PubMed, Science Direct, Web of Science, Scopus, PEDro and The Cochrane library) were searched from 1980 to October 2017. The following keywords were used: Walk* or Pedometer* or Accelerometer* or Treadmill* paired with "Back pain", "Low back pain", "Chronic low back pain", "LBP", or "Backache". Randomized controlled trials in patients with chronic LBP were included if they compared the effects of walking intervention to non-pharmacological interventions. Pain, disability, and quality of life were the primary health outcomes.

RESULTS

Nine studies were suitable for meta-analysis. Data was analyzed according to the duration of follow-up (short-term, < 3 months; intermediate-term, between 3 and 12 months; long-term, > 12 months). Low- to moderate-quality evidence suggests that walking intervention in patients with chronic LBP was as effective as other non-pharmacological interventions on pain and disability reduction in both short- and intermediate-term follow ups.

CONCLUSIONS

Unless supplementary high-quality studies provide different evidence, walking, which is easy to perform and highly accessible, can be recommended in the management of chronic LBP to reduce pain and disability.

The Recent Trend in Diagnosis and Treatment of Chronic Low Back Pain

INTRODUCTION

Development of evidence-based medicine has made a big change in diagnosis and treatment of chronic low back pain. The recent trend is assessed through a review of literature.

METHODS

The articles published in these 10 years are reviewed, and important points are examined.

RESULTS

In diagnosis, challenges for history taking and limit of imaging or clinical guidelines are revealed. In treatment, cognitive behavioral treatment and exercises are proved effective. Sleep disturbance has recently attracted attention as a factor associated with low back pain. Cost-effectiveness of diagnosis and treatment modalities has come to be emphasized.

CONCLUSIONS

Diagnosis and treatment of chronic low back pain have been significantly changing. Multidisciplinary and multidimensional approach is essential. Chronic low back pain should be treated as a total pain, not a local pain.

The effectiveness of interventions aimed at increasing physical activity in adults with persistent musculoskeletal pain: a systematic review and meta-analysis

BACKGROUND

Individuals with persistent musculoskeletal pain (PMP) have an increased risk of developing co-morbid health conditions and for early-mortality compared to those without pain. Despite irrefutable evidence supporting the role of physical activity in reducing these risks; there has been limited synthesis of the evidence, potentially impacting the optimisation of these forms of interventions. This review examines the effectiveness of interventions in improving levels of physical activity and the components of these interventions.

METHODS

Randomised and quasi-randomised controlled trials were included in this review. The following databases were searched from inception to March 2016: CENTRAL in the Cochrane Library, Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two reviewers independently screened citations, assessed eligibility, extracted data, assessed risk of bias and coded intervention content using the behaviour change taxonomy (BCTTv1) of 93 hierarchically clustered techniques. GRADE was used to rate the quality of the evidence.

RESULTS

The full text of 276 articles were assessed for eligibility, twenty studies involving 3441 participants were included in the review. Across the studies the mean number of BCTs coded was eight (range 0-16); with 'goal setting' and 'instruction on how to perform the behaviour' most frequently coded. For measures of subjective physical activity: interventions were ineffective in the short term, based on very low quality evidence; had a small effect in the medium term based on low quality evidence (SMD 0.25, 95% CI 0.01 to 0.48) and had a small effect in the longer term (SMD 0.21 95% CI 0.08 to 0.33) based on moderate quality evidence. For measures of objective physical activity: interventions were ineffective - based on very low to low quality evidence.

CONCLUSIONS

There is some evidence supporting the effectiveness of interventions in improving subjectively measured physical activity however, the evidence is mostly based on low quality studies and the effects are small. Given the quality of the evidence, further research is likely/very likely to have an important impact on our confidence in effect estimates and is likely to change the estimates. Future studies should provide details on intervention components and incorporate objective measures of physical activity.

Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial

Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity. Results Intention-to-treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physical therapy. The difference in mean change from baseline between the interventions was 2.7 points (95% confidence interval: 0.9, 4.5) on the Roland-Morris Disability Questionnaire. At 12 months, worst pain, physical activity, and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for controls. Conclusion Targeting obstacles to physical activity with an intervention that includes components to address self-efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long-term disability. Further research is needed to explore the mechanisms that impact outcomes in this intervention package. Level of Evidence Therapy, level 2b. Registered June 7, 2012 at ClinicalTrials.gov (NCT01631344). J Orthop Sports Phys Ther 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.

Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals

Overweight and obese individuals with chronic low back pain (LBP) struggle with the combined physical challenges of physical activity and pain interference during daily life; perceived disability increases, pain symptoms worsen, and performance of functional tasks and quality of life (QOL) decline. Consistent participation in exercise programs positively affects several factors including musculoskeletal pain, perceptions of disability due to pain, functional ability, QOL, and body composition. It is not yet clear, however, what differential effects occur among different easily accessible exercise modalities in the overweight-obese population with chronic LBP. This narrative review synopsizes available randomized and controlled, or controlled and comparative, studies of easily accessible exercise programs on pain severity, QOL, and other outcomes, such as physical function or body composition change, in overweight-obese persons with chronic LBP. We identified 16 studies (N = 1,351) of various exercise programs (aerobic exercise [AX], resistance exercise [RX], aquatic exercise [AQU], and yoga-Pilates) that measured efficacy on LBP symptoms, and at least one other outcome such as perceived disability, QOL, physical function, and body composition. RX, AQU, and Pilates exercise programs demonstrated the greatest effects on pain reduction, perceived disability, QOL, and other health components. The highest adherence rate occurred with RX and AQU exercise programs, indicating that these types of programs may provide a greater overall impact on relevant outcomes for overweight-obese LBP patients.

LEVEL OF EVIDENCE

V.

Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS)

BACKGROUND

The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system.

METHODS

The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory.

RESULTS

The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback.

CONCLUSIONS

The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.