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Apeldoorn AT, Swart NM, Conijn D, Meerhoff GA, Ostelo RW. Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF). Eur J Phys Rehabil Med 2024; 60:292-318. [PMID: 38407016 PMCID: PMC11112513 DOI: 10.23736/s1973-9087.24.08352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines. AIM To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists. DESIGN Clinical practice guideline. SETTING Inpatient and outpatient. POPULATION Adults with LBP and/or LRS. METHODS Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase. RESULTS The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment. CONCLUSIONS An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises. CLINICAL REHABILITATION IMPACT This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.
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Affiliation(s)
- Adri T Apeldoorn
- Department of Rehabilitation, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands -
| | - Nynke M Swart
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Daniëlle Conijn
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Guus A Meerhoff
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Raymond W Ostelo
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Free University, Amsterdam, the Netherlands
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Van den Heuvel SAS, Cohen SPC, de Andrès Ares J, Van Boxem K, Kallewaard JW, Van Zundert J. 3. Pain originating from the lumbar facet joints. Pain Pract 2024; 24:160-176. [PMID: 37640913 DOI: 10.1111/papr.13287] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Pain originating from the lumbar facets can be defined as pain that arises from the innervated structures comprising the joint: the subchondral bone, synovium, synovial folds, and joint capsule. Reported prevalence rates range from 4.8% to over 50% among patients with mechanical low back pain, with diagnosis heavily dependent on the criteria employed. In well-designed studies, the prevalence is generally between 10% and 20%, increasing with age. METHODS The literature on the diagnosis and treatment of lumbar facet joint pain was retrieved and summarized. RESULTS There are no pathognomic signs or symptoms of pain originating from the lumbar facet joints. The most common reported symptom is uni- or bilateral (in more advanced cases) axial low back pain, which often radiates into the upper legs in a non-dermatomal distribution. Most patients report an aching type of pain exacerbated by activity, sometimes with morning stiffness. The diagnostic value of abnormal radiologic findings is poor owing to the low specificity. SPECT can accurately identify joint inflammation and has a predictive value for diagnostic lumbar facet injections. After "red flags" are ruled out, conservatives should be considered. In those unresponsive to conservative therapy with symptoms and physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic medial branch block can be performed which remains the most reliable way to select patients for radiofrequency ablation. CONCLUSIONS Well-selected individuals with chronic low back originating from the facet joints may benefit from lumbar medial branch radiofrequency ablation.
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Affiliation(s)
- Sandra A S Van den Heuvel
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven P C Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Koen Van Boxem
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Tito N, Porter E, Castonguay T, Dover G. Longitudinal Validation of a Specific Measure of Fear Avoidance in Athletes: Predicting Time from Injury to Return to Sports Competition. J Pain Res 2023; 16:1103-1114. [PMID: 37020665 PMCID: PMC10069429 DOI: 10.2147/jpr.s396054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/18/2023] [Indexed: 03/31/2023] Open
Abstract
Purpose We developed the Athlete Fear Avoidance Questionnaire (AFAQ) to measure fear avoidance in athletes. Previous fear avoidance scales were developed for the general population and have demonstrated significant predictive capabilities regarding rehabilitation. No research to date has examined the association between athlete fear avoidance as measured by the AFAQ and the rehabilitation time in athletes. Patients and Methods Fifty-nine athletes who were injured during sport season participated in the study (40 males and 19 females). At injury onset, all participants completed self-report functional questionnaires. In addition, we measured multiple aspects of fear avoidance including athlete fear avoidance (AFAQ), kinesiophobia (TSK), and pain catastrophizing (PCS). Finally, we assessed pain severity and interference, as well as depression. Once the athletes were able to return to competition all participants answered the questionnaires again. Pearson correlations and a regression analysis were used to identify relationships between function, psychological variables, pain, and return to competition time. Results The AFAQ yielded the strongest correlation with return to competition time (r=0.544, p<0.001). In addition, function at initial injury time and pain interference were also significantly correlated with return to competition time (r=0.442, p<0.001 and r=0.356, p=0.006 respectively). Athlete fear-avoidance combined with function at the time of injury explained 34% of the variance of return to competition time in the multivariate regression model (p<0.001). Conclusion Athlete fear-avoidance as measured by the AFAQ is associated with rehabilitation time and returning to competition in injured athletes. Psychosocial factors including athlete fear avoidance may explain why some athletes take longer to rehabilitate than others and should be evaluated in athletes who are taking longer than anticipated to complete their rehabilitation. Reducing athlete fear avoidance may facilitate rehabilitation in future studies.
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Affiliation(s)
- Noémie Tito
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, QC, Canada
| | - Erica Porter
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, QC, Canada
| | - Tristan Castonguay
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, QC, Canada
| | - Geoffrey Dover
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, QC, Canada
- Correspondence: Geoffrey Dover, Department of Health, Kinesiology, and Applied Physiology, Concordia University, 7141 Sherbrooke Street West, Montreal, QC, Canada, Tel +1 514 848 2424 Ext 3304, Fax +1 514 848 8681, Email
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Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2022; 52:67-84. [PMID: 34775831 DOI: 10.2519/jospt.2022.10761] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP). DESIGN Systematic review with meta-analysis. LITERATURE SEARCH The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened. STUDY SELECTION CRITERIA We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded. DATA SYNTHESIS Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration. RESULTS Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. CONCLUSION For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.
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George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther 2021; 51:CPG1-CPG60. [PMID: 34719942 PMCID: PMC10508241 DOI: 10.2519/jospt.2021.0304] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.
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Chys M, Cagnie B, De Meulemeester K, Bontinck J, Meeus M, Dewitte V. Evaluating the effectiveness of patient tailored treatment for patients with non-specific low back pain: A systematic review. Musculoskeletal Care 2021; 20:31-46. [PMID: 34058064 DOI: 10.1002/msc.1572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This systematic review summarizes the relevant literature on the effectiveness of tailored interventions in non-specific low back pain (NSLBP). METHODS The search strategy has been executed in December 2019 in the electronic databases PubMed, Web of Science and Embase. Study selection, data extraction and quality assessment were done independently by two authors. RESULTS A total six eligible studies were identified. Five out of six articles used a classification system to subgroup patients. All active patient tailored interventions had similar or better results than the non-patient tailored interventions, most importantly on pain (short- and mid-term, not for long term follow-up). Two motor control interventions revealed sustained or increased effects at 12 months follow-up for disability. For cost-effectiveness, medication use and work absenteeism, results were inconclusive. Global rating of change evaluation confirmed significant between-group results at 10 weeks to 4 months follow-up, but results were not maintained at 12-month evaluation. DISCUSSION & CONCLUSION: Our findings support the preliminary evidence for the use of patient tailored treatment for reductions in pain and disability. However, our results are of very low to moderate quality evidence and the observed effects strongly depend on the subgroups and the chosen interventions. More high-quality RCT's with homogenous designs and larger sample sizes are needed.
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Affiliation(s)
- M Chys
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - B Cagnie
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - K De Meulemeester
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - J Bontinck
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - M Meeus
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - V Dewitte
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
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de Zoete A, Rubinstein SM, de Boer MR, Ostelo R, Underwood M, Hayden JA, Buffart LM, van Tulder MW. The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis. Physiotherapy 2021; 112:121-134. [PMID: 34049207 DOI: 10.1016/j.physio.2021.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect. PURPOSE To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis. DATA SOURCES Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews. STUDY SELECTION Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator. DATA EXTRACTION AND DATA SYNTHESIS We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT. RESULTS Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings. LIMITATIONS Only 50% of the eligible trials were included. CONCLUSIONS Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Michiel R de Boer
- Department of General Practice and Elderly Care Medicine, UMCG, the Netherlands.
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK; University Hospitals of Coventry and Warwickshire, Coventry CV2 2DX, UK.
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia B3H 1V7, Canada.
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark.
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