Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial

ARBOR-Telehealth study: an examination of telerehabilitation to improve function and reduce opioid use in persons with chronic low back pain in rural communities - protocol of a pragmatic, individually randomised group treatment trial

INTRODUCTION

Chronic low back pain (LBP) imposes significant burden on patients, healthcare systems and society. Physical therapy is a cost-effective method for improving pain and disability; however, only a small number of patients (7-13%) with LBP ever receive physical therapy services. Patients report obstacles to accessing physical therapy, such as transportation, provider availability and missed work. Access is especially limited in rural communities, where approximately 40% fewer physical therapists are available per capita than in metropolitan regions. This lack of access likely contributes to the greater rates of LBP-related disability and opioid consumption in rural communities. Innovative methods for improving access to physical therapy for patients with chronic LBP are urgently needed; these can help address differences in health outcomes and mitigate opioid dependence for patients with chronic LBP living in rural communities. Telerehabilitation increases access to physical therapy, which can potentially improve health outcomes for these patients.

METHODS AND ANALYSIS

This prospective, individually randomised group treatment trial will involve primary care clinics serving rural communities on Maryland's Eastern Shore. We will enroll 434 individuals with chronic LBP. Eligible patients will be randomised to either standardised education for back pain delivered via website or to a risk-informed telerehabilitation. Standardised education will be delivered via a study website containing information consistent with materials provided by primary care providers. Risk-informed telerehabilitation will be delivered by trained physical therapists using a web-based, video-enabled telehealth platform. The primary outcome is LBP-related disability. Secondary outcomes are opioid use, pain intensity, health-related quality of life and LBP-related healthcare use assessed using standard patient-reported outcome measures, participant self-report and medical chart abstraction. Implementation outcomes are acceptability, adoption, feasibility and fidelity of our treatment approach guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and assessed using surveys, semi-structured interviews and key performance metrics.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Johns Hopkins Medicine Institutional Review Boards (IRB), which serves as the single IRB for this trial. Upon completion, study data will be shared in compliance with National Institutes of Health guidelines.

TRIAL REGISTRATION NUMBER

NCT06471920.

Optimizing osteoarthritis care through clinical and community partnership: Results of an exploratory trial

Background/Purpose

To conduct an exploratory trial of a clinic-community care model (OA CARE) for managing osteoarthritis (OA).

Design

Participants (n ​= ​60) with symptomatic knee or hip OA and overweight/obesity were randomized to OA CARE or a usual care control group (UC). Participants in the OA CARE group received a 12-month medical membership to a local YMCA, which included a 12-week weight loss program and access to exercise programming, as well as referrals to rehabilitation, nutrition, sleep-related and psychological services. Participants' primary care clinicians were given a video-based summary of OA treatment guidelines. Feasibility metrics included engagement with the weight loss program and exercise resources. Outcomes were assessed at baseline, 6-months and 12-months. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Outcomes were analyzed between groups across time points using general linear mixed models.

Results

Eighty-seven percent of the OA CARE group participated in the weight loss program, with a mean attendance of 9.2 sessions; 57 ​% participated in an exercise class. At 6-months, there was a statistically significant between-group difference in change in WOMAC total scores, with the OA CARE group showing greater improvement (-11.0, 95 ​% Confidence Interval -20.1, -1.9). At 12-months, the between-group change in WOMAC score was not statistically significant, though there was a small difference in favor of OA CARE Group (-4.9, 95 ​% Confidence Interval -14.1, 4.3).

Conclusion

Feasibility metrics were positive, but effects of OA CARE were modest, and a more intensive approach may be needed to enhance impacts.

Prognostic Factors and Models for Predicting Work Absence in Adults with Musculoskeletal Conditions Consulting a Healthcare Practitioner: A Systematic Review

PURPOSE

It is difficult to predict which employees, in particular those with musculoskeletal pain, will return to work quickly without additional vocational advice and support, which employees will require this support and what levels of support are most appropriate. Consequently, there is no way of ensuring the right individuals are directed towards the right services to support their occupational health needs. The aim of this review will be to identify prognostic factors for duration of work absence in those already absent and examine the utility of prognostic models for work absence.

METHODS

Eight databases were search using a combination of subject headings and key words focusing on work absence, musculoskeletal pain and prognosis. Two authors independently assessed the eligibility of studies, extracted data from all eligible studies and assessed risk of bias using the QUIPS or PROBAST tools, an adapted GRADE was used to assess the strength of the evidence. To make sense of the data prognostic variables were grouped according to categories from the Disability Prevention Framework and the SWiM framework was utilised to synthesise findings.

RESULTS

A total of 23 studies were included in the review, including 13 prognostic models and a total of 110 individual prognostic factors. Overall, the evidence for all prognostic factors was weak, although there was some evidence that older age and better recovery expectations were protective of future absence and that previous absence was likely to predict future absences. There was weak evidence for any of the prognostic models in determining future sickness absence.

CONCLUSION

Analysis was difficult due to the wide range of measures of both prognostic factors and outcome and the differing timescales for follow-up. Future research should ensure that consistent measures are employed and where possible these should be in-line with those suggested by Ravinskaya et al. (2023).

Psychological and behavioural interventions delivered by non-psychologists

Psychologically Informed Practice (PiP) is best understood as enhanced physiotherapy in which identification and management of psychological factors is central to reactivation. The PiP approach has been investigated in trials of stratified care linking psychological screening with targeted treatment, but there have been challenges in its implementation in routine musculoskeletal care. The possible reasons for this have been carefully explored and raise questions about both the adequacy of training and the feasibility of implementation of PiP in clinical practice. Recommendations are made for the further development of PiP, the management of psychological obstacles to recovery, and the role of psychologists in this process.

Comparison of baseline PROMIS-10 scores of mental and physical health of patients with low back pain evaluated by physiatrists and orthopedic spine surgeons

BACKGROUND

Enabling spine patients to access appropriate spine providers based on their course of care can enhance care outcomes. Physiatrists are trained to provide care throughout the continuum of low-back pain (LBP) symptoms and structural conditions that do not require urgent/emergent spine structural intervention.

OBJECTIVE

To assess if patients triaged to a physiatrist for LBP based on where they are in their continuum of spine care will report better baseline physical and mental health than patients presenting to a spine surgeon.

DESIGN

Retrospective study comparing physical and mental health (Patient-Reported Outcomes Measurement Information System [PROMIS]-10) in patients with LBP who are triaged for initial evaluations with physiatrists or spine surgeons.

SETTING

Tertiary orthopedic hospital.

PATIENTS

Adult patients presenting with chief concerns of nonemergent/nonurgent LBP to physiatry or spine surgery from April 1, 2019 to July 1, 2021.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Initial-visit PROMIS-10 mental and physical health scores.

RESULTS

A total of 2646 new patients presented to physiatrists (n = 1911 [72.2%]) and spine surgeons (n = 735 [27.8%]). Patients evaluated by physiatrists had higher mental health (physiatry 50.1 ± 8.5, spine surgery 46.7 ± 9.0; p < .001) and physical health scores (physiatry 43.7 ± 7.5, spine surgery 39.8 ± 7.2; p < .001) than those presenting to spine surgeons. Furthermore, patients evaluated by physiatrists were more likely to have mental and physical health scores >55 and less likely to have scores <45 (p ≤ .001). Patients with LBP + lower extremity (LE) pain had significantly lower mental and physical health scores than those with LBP alone (mental health 48.5 ± 8.6 [LBP + LE-pain], 49.9 ± 8.9 [LBP-alone]; physical health 41.5 ± 7.3 [LBP + LE-pain], 44.0 ± 7.7 [LBP-alone]; p < .001).

CONCLUSIONS

Patients directed to spine surgeons via triage had worse PROMIS-10 mental and physical health, suggesting this subgroup of patients may especially need additional resources to address these issues in the course of their care. Physiatrists provided nearly two-thirds of nonurgent LBP evaluations in this tertiary orthopedic center, serving an important role in the initial evaluation and treatment of nonurgent LBP. The impact on patient outcomes, patient satisfaction, and associated health care costs requires further investigation.

Clinical and cost-effectiveness of a personalised guided consultation versus usual physiotherapy care in people presenting with shoulder pain: a protocol for the PANDA-S cluster randomised controlled trial and process evaluation

INTRODUCTION

Musculoskeletal shoulder pain is a common reason for people to be treated in physiotherapy services, but diagnosis can be difficult and often does not guide treatment or predict outcome. People with shoulder pain cite a need for clear information, and timely, tailored consultations for their pain. This trial will evaluate the introduction of a personalised guided consultation to help physiotherapists manage care for individuals with shoulder pain.

METHODS AND ANALYSIS

This is a cluster randomised controlled trial to evaluate the clinical and cost-effectiveness of introducing a personalised guided consultation compared with usual UK NHS physiotherapy care. Physiotherapy services (n=16) will be randomised in a 1:1 ratio to either intervention (physiotherapy training package and personalised guided consultation incorporating a new prognostic tool) or control (usual care); 832 participants (416 in each arm) identified from participating physiotherapy service waiting lists aged 18 years or over with shoulder pain will be enrolled. Follow-up will occur at 3 time points: 6 weeks, 6 months and 12 months. The primary outcome will be the Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes include global perceived change of the shoulder condition, sleep, work absence and the impact of shoulder pain on work performance, healthcare utilisation and health-related quality of life (using EuroQol 5 Dimension 5 Level (EQ-5D-5L)). A multimethod process evaluation will investigate views and experiences of participants and physiotherapists, assess uptake, facilitators and barriers to delivery, and changes in factors assumed to explain intervention outcomes. Primary analysis of effectiveness will be by intention-to-treat, and a health economic evaluation will assess cost-utility of introducing the personalised consultation.

ETHICS AND DISSEMINATION

The trial received ethics approval from the Yorkshire & The Humber (South Yorkshire) Research Ethics Committee (REC reference: 23/YH/0070). Findings will be shared through journal publications, media outlets and conference presentations. Supported by patient contributors and clinical advisors, we will communicate findings through a designated website, networks, newsletters, leaflets and in the participating physiotherapy services.

TRIAL REGISTRATION NUMBER

ISRCTN45377604.

Low back pain among the working-age population: from the global burden of disease study 2021

BACKGROUND

The burden of low back pain in the global working-age population (WAP) is substantial and exhibits unique characteristics. This study aimed to evaluate global, regional, and national trends in low back pain prevalence among the WAP over a 32-year period.

METHODS

We utilized data from the 2021 Global Burden of Disease (GBD) study to evaluate the global impact of low back pain in the WAP from 1990 to 2021. A secondary analysis focused on temporal trends and a decomposition analysis of low back pain.

RESULTS

From 1990 to 2021, there was a continuous decrease in the rate of low back pain among the global WAP. The age-standardized incidence rate (ASIR) decreased from 4,111 (95% uncertainty interval [UI]: 2,682-5,619) to 3,676 (95% UI: 2,563-5,021), with an annual average percentage change (AAPC) of -0.36. The age-standardized prevalence rate (ASPR) decreased from 9,731 (95% UI: 7,061-12,970) to 8,632 (95% UI: 6,296-11,517), with an AAPC of -0.39. The age-standardized disability-adjusted life years (DALYs) rate (ASDR) decreased from 1,108 (95% UI: 686-1,650) to 982 (95% UI: 608-1,460), with an AAPC of -0.39. However, the number of low back pain cases in the global WAP continued to increase. Regions with a middle Socio-demographic Index (SDI), South Asia, China, and India carried a heavier burden of low back pain in the WAP. The burden was also greater among females, with the gender gap continuing to widen. Decomposition analysis revealed that population growth and population aging were the predominant driving factors.

CONCLUSIONS

Despite the overall reduction in the ASIR, ASPR, and ASDR of low back pain among WAP, it remained a leading cause of disability worldwide. More attention needs to be paid to the low back pain burden among WAP in middle-SDI regions, countries with a large population base, and females. Significant gender and regional disparities persist within WAP, highlighting the necessity for targeted preventive and therapeutic interventions to alleviate the burden of low back pain and reduce the risks of disability.

Personalised decision support in the management of patients with musculoskeletal pain in primary physiotherapy care: a cluster randomised controlled trial (the SupportPrim project)

ABSTRACT

We developed the SupportPrim PT clinical decision support system (CDSS) using the artificial intelligence method case-based reasoning to support personalised musculoskeletal pain management. The aim of this study was to evaluate the effectiveness of the CDSS for patients in physiotherapy practice. A cluster randomised controlled trial was conducted in primary care in Norway. We randomised 44 physiotherapists to (1) use the CDSS alongside usual care or (2) usual care alone. The CDSS provided personalised treatment recommendations based on a case base of 105 patients with positive outcomes. During the trial, the case-based reasoning system did not have an active learning capability; therefore, the case base size remained the same throughout the study. We included 724 patients presenting with neck, shoulder, back, hip, knee, or complex pain (CDSS; n = 358, usual care; n = 366). Primary outcomes were assessed with multilevel logistic regression using self-reported Global Perceived Effect (GPE) and Patient-Specific Functional Scale (PSFS). At 12 weeks, 165/298 (55.4%) patients in the intervention group and 176/321 (54.8%) in the control group reported improvement in GPE (odds ratio, 1.18; confidence interval, 0.50-2.78). For PSFS, 173/290 (59.7%) patients in the intervention group and 218/310 (70.3%) in the control group reported clinically important improvement in function (odds ratio, 0.41; confidence interval, 0.20-0.85). No significant between-group differences were found for GPE. For PSFS, there was a significant difference favouring the control group, but this was less than the prespecified difference of 15%. We identified several study limitations and recommend further investigation into artificial intelligence applications for managing musculoskeletal pain.

Work Disability Prevention and Management

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Work Disability Prevention and Management Guideline reviews the available evidence and provides recommendations to clinicians regarding interventions to help patients remain at or return to work.

METHODS

Systematic literature reviews were conducted. Studies were graded and evidence tables were created, with involvement of a multidisciplinary expert panel that evaluated the evidence and finalized recommendations for all clinical questions. Extensive peer review was performed. Consensus recommendations were formulated when evidence was lacking.

RESULTS

Evidence-based recommendations have been developed to guide work disability prevention and management.

CONCLUSIONS

Clinicians should utilize quality evidence in determining treatment methods to prevent and alleviate work disability for workers. This guideline offers an evidence-based framework for preventing and mitigating work disability for individual adults in the active workforce. It is designed for use by healthcare clinicians who desire to minimize the negative impact of health conditions on working people's lives and livelihoods.

Supporting self-management with an internet intervention for low back pain in primary care: a RCT (SupportBack 2)

Background

Low back pain is highly prevalent and a leading cause of disability. Internet-delivered interventions may provide rapid and scalable support for behavioural self-management. There is a need to determine the effectiveness of highly accessible, internet-delivered support for self-management of low back pain.

Objective

To determine the clinical and cost-effectiveness of an accessible internet intervention, with and without physiotherapist telephone support, on low back pain-related disability.

Design

A multicentre, pragmatic, three parallel-arm randomised controlled trial with parallel economic evaluation.

Setting

Participants were recruited from 179 United Kingdom primary care practices.

Participants

Participants had current low back pain without indicators of serious spinal pathology.

Interventions

Participants were block randomised by a computer algorithm (stratified by severity and centre) to one of three trial arms: (1) usual care, (2) usual care + internet intervention and (3) usual care + internet intervention + telephone support. 'SupportBack' was an accessible internet intervention. A physiotherapist telephone support protocol was integrated with the internet programme, creating a combined intervention with three brief calls from a physiotherapist.

Outcomes

The primary outcome was low back pain-related disability over 12 months using the Roland-Morris Disability Questionnaire with measures at 6 weeks, 3, 6 and 12 months. Analyses used repeated measures over 12 months, were by intention to treat and used 97.5% confidence intervals. The economic evaluation estimated costs and effects from the National Health Service perspective. A cost-utility study was conducted using quality-adjusted life-years estimated from the EuroQol-5 Dimensions, five-level version. A cost-effectiveness study estimated cost per point improvement in the Roland-Morris Disability Questionnaire. Costs were estimated using data from general practice patient records. Researchers involved in data collection and statistical analysis were blind to group allocation.

Results

Eight hundred and twenty-five participants were randomised (274 to usual primary care, 275 to usual care + internet intervention and 276 to the physiotherapist-supported arm). Follow-up rates were 83% at 6 weeks, 72% at 3 months, 70% at 6 months and 79% at 12 months. For the primary analysis, 736 participants were analysed (249 usual care, 245 internet intervention, 242 telephone support). There was a small reduction in the Roland-Morris Disability Questionnaire over 12 months compared to usual care following the internet intervention without physiotherapist support (adjusted mean difference of -0.5, 97.5% confidence interval -1.2 to 0.2; p = 0.085) and the internet intervention with physiotherapist support (-0.6, 97.5% confidence interval -1.2 to 0.1; p = 0.048). These differences were not statistically significant at the level of 0.025. There were no related serious adverse events. Base-case results indicated that both interventions could be considered cost-effective compared to usual care at a value of a quality-adjusted life-year of £20,000; however, the SupportBack group dominated usual care, being both more effective and less costly.

Conclusions

The internet intervention, with or without physiotherapist telephone support, did not significantly reduce low back pain-related disability across 12 months, compared to usual primary care. The interventions were safe and likely to be cost-effective. Balancing clinical effectiveness, cost-effectiveness, accessibility and safety findings will be necessary when considering the use of these interventions in practice.

Trial registration

This trial is registered as ISRCTN14736486.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/111/78) and is published in full in Health Technology Assessment; Vol. 29, No. 7. See the NIHR Funding and Awards website for further award information.

Subgrouping People With Acute Low Back Pain Based on Psychological, Sensory, and Motor Characteristics: A Cross-Sectional Study

BACKGROUND

Clustering helps identify patient subgroups with similar biopsychosocial profiles in acute low-back pain (LBP). Motor factors are common treatment targets and are associated with disability but have not been included in acute LBP cluster development. This study aimed to identify subgroups of individuals with acute LBP based on motor, sensory and psychological characteristics and to compare these subgroups regarding clinical outcomes.

METHODS

Ninety-nine participants with acute LBP were recruited, and motor (bending range of motion [ROM], flexion relaxation), pain sensitivity (pressure-pain thresholds, temporal summation of pain) and psychological factors (pain catastrophising, kinesiophobia, self-efficacy) were measured, along with pain, disability and demographics.

RESULTS

Principal component analysis accounted for 66.03% of the variance. Four component scores were entered in a hierarchical linear clustering model, deriving 3 subgroups ('mild features' n = 39, 'sensorimotor' n = 35 and 'psychomotor' n = 25). Between-cluster comparisons revealed significant differences in motor, sensory and psychological variables (p < 0.05). Sensorimotor and psychomotor clusters had higher flexion-relaxation ratios (mean difference: > 0.2), greater disability (mean difference: > 7/100) and smaller ROM (mean difference: 7 cm) compared to the 'mild' group. The sensorimotor cluster mostly exhibited higher temporal summation of pain (mean difference: > 1.3/10) and lower pressure-pain thresholds (mean difference: > 1.2 kg/cm2) than 'mild' and psychomotor clusters. The psychomotor cluster showed higher kinesiophobia (mean difference: > 6/44) and pain catastrophising (mean difference: > 12/52) than 'mild' and sensorimotor groups.

CONCLUSION

Findings indicate 3 subgroups, suggesting that motor factors may add granularity to acute LBP clusters. Stratified care based on these subgroups may help refine treatment pathways for acute LBP.

SIGNIFICANCE STATEMENT

Including motor factors in cluster development adds a clinically relevant metric to describe people with acute LBP and generates insight into underlying mechanisms of motor adaptation. Longitudinal testing is required to see if these subgroups are differentially related to short- and long-term pain and disability.

Reassurance use and reassurance-related outcomes for low back pain in primary care: A scoping review

We used a scoping review design to map the available evidence describing the use of reassurance in clinical practice, interventions to increase the delivery of reassurance, and reassurance-related outcome measures. We searched CINAHL, MEDLINE, EMBASE and Cochrane Central from inception to October 2024. Publications were included if they described the use of reassurance or reassurance-related outcome measures in patients with non-specific low back pain (LBP) presenting to primary care. We did not exclude publications on the basis of study design. Data were extracted and charted in accordance with study aims. We included 88 publications describing 66 primary studies. Twenty-one papers described how clinicians used reassurance in primary care, including: information provided (n=16), frequency of use (n=6), challenges providing reassurance (n=7), and importance of individualising reassurance (n=11). Reassurance interventions were investigated in 46 trials. Reassurance interventions were delivered verbally by clinicians to individuals (n=29) or groups (n=14), or via educational materials (n=18). Only one trial measured how reassured the patient felt after the intervention using a single-item non-validated question. Thirty-six trials used indirect measurements of reassurance success, including reductions in: fear-avoidance (n=23), worry (n=8), anxiety (n=8), pain catastrophising (n=10), and further healthcare utilisation (n=12). Relatively few papers have described how clinicians use reassurance in primary care. Reassurance interventions were investigated in 46 trials; however, reassurance was rarely the primary component of the intervention and was often delivered as part of an education intervention. There are no validated measures to directly assess how reassured a patient feels after an intervention. PERSPECTIVE: This review maps the available evidence describing how patient reassurance is used and assessed in the management of low back pain. There is limited assessment of the effectiveness of reassurance interventions. Reassurance is rarely the primary component of interventions and there are no validated measures to directly assess patient reassurance.

Enhancing psychological assessment and treatment of chronic pain: A research agenda for personalized and process-based approaches

The heterogeneity of chronic pain and stagnating improvements in treatment effectiveness have prompted calls for a shift toward personalized and process-based approaches to the assessment and treatment of chronic pain. As this opens a new line of research, several fundamental questions arise. We begin by defining key terms and reviewing attempts to personalize treatment to date. Despite progress in personalization, long-term effects remain unclear. Existing studies are limited by group-based approaches that overlook individual variability. Future research should use idiographic methods and process-based therapy to tailor interventions to individual needs. A person- and process-oriented research agenda is needed that combines ambulatory assessment, network modeling, and single-case designs to advance personalized treatments for chronic pain and improve clinical decision-making.

Risk-stratified Care Improves Pain-related Knowledge and Reduces Psychological Distress for Low Back Pain: A Secondary Analysis of a Randomized Trial

BACKGROUND

A number of efforts have been made to tailor behavioral healthcare treatments to the variable needs of patients with low back pain (LBP). The most common approach involves the STarT Back Screening Tool (SBST) to triage the need for psychologically informed care, which explores concerns about pain and addresses unhelpful beliefs, attitudes, and behaviors. Such beliefs that pain always signifies injury or tissue damage and that exercise should be avoided have been implied as psychosocial mediators of chronic pain and can impede recovery. The ability of physical therapy interventions guided by baseline stratification for risk of persistent LBP or related functional limitations to improve unhelpful pain beliefs has not been well assessed. Because treatments are aimed at addressing these beliefs, understanding a bit more about the nature of beliefs about pain (for example, attitudes and knowledge) might help us understand how to better tailor this care or even our risk-stratification approaches for future treatment of patients with LBP.

QUESTIONS/PURPOSES

(1) Did patients assigned to receive risk-stratified care score higher on an assessment of pain science knowledge? (2) Did patients assigned to receive risk-stratified care have fewer unhelpful attitudes related to pain? (3) Did patients assigned to receive risk-stratified care have less pain-associated psychological distress? (4) Regardless of intervention received, is baseline SBST risk category (low, medium, or high) associated with changes in attitudes and knowledge about pain?

METHODS

This is a secondary analysis of short-term changes in pain beliefs following the 6-week treatment phase of a randomized controlled trial that examined the effectiveness of a risk-stratified physical therapy intervention on pain-related disability at 1 year. Between April 2017 and February 2020, a total of 290 patients in the Military Health System seeking primary care for LBP were enrolled in a trial comparing a behavioral-based intervention to usual care. The intervention involved psychologically informed physical therapy using cognitive behavioral principles and included tailored education, graded exercise, and graded exposure. Individuals assigned to usual care followed treatment plans set forth by their primary care provider. Thirty-one patients were removed from Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool analyses due to missing assessments at 6 weeks (n = 15 intervention; n = 16 usual care). This resulted in 89% (259 of 290) of participants included for secondary analysis, with no difference in baseline demographic characteristics between groups. The usual-care group comprised 50% of the total study group (129 of 259), with a mean age of 34 ± 9 years; 67% (87 of 129) were men. The risk-stratified care group comprised 50% (130 of 259) of the total study group, with a mean ± SD age of 35 ± 8 years; 64% (83 of 130) were men. Six additional individuals were removed from Survey of Pain Attitudes harm scale (SOPA-h) and revised Neurophysiology of Pain Questionnaire (rNPQ) analyses for missing baseline data (n = 1 intervention) and 6-week data (n = 2 intervention; n = 3 usual care). The rNPQ captured current pain science knowledge, the SOPA-h examined patient attitudes about pain (the extent of beliefs that pain leads to damage and that movement is harmful), and the OSPRO-YF assessed patients for yellow flag clinical markers of pain-related psychological distress across 11 constructs within domains of negative mood, fear avoidance, and positive affect/coping indicative of elevated vulnerability and decreased resilience. Outcomes were assessed at baseline and 6 weeks, and data were analyzed per protocol. We assessed between-group differences at 6 weeks using linear mixed-effects models of pain attitudes and knowledge and related distress, controlling for age, gender, and baseline pain. Regardless of treatment group, we also analyzed differences in rNPQ and SOPA-h scores at 6 weeks based on SBST risk category (low versus medium or high) using generalized linear (Gaussian) regression models.

RESULTS

Risk-stratified treatment was associated with improvements in pain knowledge (rNPQ mean difference 6% [95% confidence interval (CI) 1% to 11%]; p = 0.01) and a reduction in indicators of pain-associated psychological distress (OSPRO-YF mean difference -1 [95% CI -2 to 0]; p = 0.01) at 6 weeks compared with usual care. There was no difference between groups for SOPA-h score at 6 weeks (mean difference -0.2 [95% CI -0.3 to 0.0]; p = 0.09). Patients with medium- or high-risk scores on the SBST, regardless of intervention, improved slightly more on SOPA-h (β = -0.31; p < 0.01) but not rNPQ (β = 0.02; p = 0.95) than those scoring low risk.

CONCLUSION

Patients receiving risk-stratified care showed small improvements in pain knowledge and reductions in pain-related psychological distress at 6 weeks, immediately after intervention, compared with usual care. Implementation of this risk-stratified care approach for LBP was able to change patients' perceptions about pain and reduce some of their psychological distress beyond what was achieved by usual care in this setting. As these factors are believed to favorably mediate treatment outcomes, future studies should investigate whether these improvements persist over the long term, determine how they influence clinical outcomes, and explore alternatives for risk stratification and treatment to elicit greater improvements.Level of Evidence Level III, therapeutic study.

Efficacy and Safety of the Combination of Diclofenac and Thiocolchicoside in the Treatment of Low Back Pain and Other Conditions: Systematic Review of the Literature

Background/Objectives: Low back pain (LBP) is a leading cause of disability worldwide. Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), and thiocolchicoside, a muscle relaxant, are commonly combined to target inflammation and muscle spasm. However, the efficacy and safety of their combination remain under discussion. This systematic review evaluates the efficacy and safety of diclofenac-thiocolchicoside therapy for LBP and other musculoskeletal conditions. Methods: A systematic review was conducted following PRISMA guidelines. Eligible studies included randomized controlled trials (RCTs) and observational studies comparing diclofenac-thiocolchicoside combination with placebo, monotherapy, or alternative treatments. A search was performed in PubMed, Scopus, and relevant websites, identifying articles published up to 30 September 2024. Studies from trial registries were excluded. Risk of bias was assessed using Revised Cochrane Risk of Bias for randomized trials (RoB 2) for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies. Evidence certainty was evaluated with the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Results were visualized using Robvis, tables, and graphs. Results: Of 393 identified records, 9 studies (1097 patients) met the inclusion criteria. Seven RCTs reported significant pain reduction and functional improvement with combination therapy compared to placebo or active controls. However, study heterogeneity, dosage variations, and risk of bias limited comparability. Adverse events (AEs) included gastrointestinal (GI) discomfort and drowsiness, though no severe complications were consistently reported. Conclusions: Despite methodological limitations, the diclofenac-thiocolchicoside combination demonstrates promising efficacy for acute LBP and musculoskeletal pain management. However, there is no clear evidence of its clinical superiority over other available treatments, due to study heterogeneity and potential biases. Rigorous, standardized research with larger sample sizes and consistent methodologies is essential to definitively establish the efficacy and safety of diclofenac-thiocolchicoside, providing clearer guidance for clinical decision-making.

Patients' Experiences Participating Within an Interdisciplinary Primary Care Program for Low Back Pain

A common recommendation to improve the management of low back pain (LBP) is the use of interdisciplinary teams. However, many challenges remain in establishing interdisciplinary care, particularly in community-based primary care settings. This study explored patients' experiences with interdisciplinary care for LBP using an applied phenomenological research approach. Semistructured open-ended interviews were conducted with fifteen adults enrolled in a 6-month interdisciplinary LBP program within an integrated care network. The analysis included detailed descriptions of participants' experiences and interpretations by the researchers of the main themes: (i) challenging start-"It's intimidating," (ii) desire for flexibility-"I didn't need as much," (iii) better collaboration-"They are all together," (iv) grasping the pain issue-"They helped," (v) care was responsive to needs and experience-"Always centered on me, not general," (vi) meanings of recovery-"I'm able to function." Participants viewed the interdisciplinary LBP program as the culmination of a long journey toward recovery. The findings identified as important to patients contribute to our understanding of how to optimize patient-centered care for individuals living with chronic pain.

Models of care for managing non-specific low back pain

BACKGROUND

Alternative care models seek to improve the quality or efficiency of care, or both, and thus optimise patient health outcomes. They provide the same health care but change how, when, where, or by whom health care is delivered and co-ordinated. Examples include care delivered via telemedicine versus in-person care or care delivered to groups versus individual patients.

OBJECTIVES

To assess the effects of alternative models of evidenced-based care for people with non-specific low back pain on the quality of care and patient self-reported outcomes and to summarise the availability and principal findings of economic evaluations of these alternative models.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries up to 14 June 2024, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials comparing alternative care models to usual care or other care models. Eligible trials had to investigate care models that changed at least one domain of the Cochrane EPOC delivery arrangement taxonomy and provide the same care as the comparator arm. Participants were individuals with non-specific low back pain, regardless of symptom duration. Main outcomes were quality of care (referral for/receipt of lumbar spine imaging, prescription/use of opioids, referral to a surgeon/lumbar spine surgery, admission to hospital for back pain), patient health outcomes (pain, back-related function), and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was alternative models of care versus usual care at closest follow-up to 12 months.

MAIN RESULTS

Fifty-seven trials (29,578 participants) met our inclusion criteria. Trials were primarily set within primary care (18 trials) or physiotherapy practices (15 trials) in high-income countries (51 trials). Forty-eight trials compared alternative models of care to usual care. There was substantial clinical diversity across alternative care models. Alternative care models most commonly differed from usual care by altering the co-ordination/management of care processes (18 trials), or by utilising information and communication technology (10 trials). Moderate-certainty evidence indicates that alternative care models probably result in little difference in referral for or receipt of any lumbar spine imaging at follow-up closest to 12 months compared to usual care (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.86 to 0.98; I2 = 2%; 18 trials, 16,157 participants). In usual care, 232/1000 people received lumbar spine imaging compared to 213/1000 people who received alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). Moderate-certainty evidence suggests that alternative care models probably result in little or no difference in the prescription or use of opioid medication at follow-up closest to 12 months compared to usual care (RR 0.95, 95% CI 0.89 to 1.03; I2 = 0%; 15 trials, 13,185 participants). In usual care, 349 out of 1000 people used opioid medication compared to 332 out of 1000 people in alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter referral for or use of lumbar spine surgery at follow-up closest to 12 months compared to usual care as the certainty of the evidence was very low (odds ratio (OR) 1.04, 95% CI 0.79 to 1.37; I2 = 0%; 10 trials, 4189 participants). We downgraded the certainty of the evidence by three levels due to very serious imprecision (wide CIs) and serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter hospital admissions for non-specific low back pain at follow-up closest to 12 months compared to usual care as the certainty of evidence was very low (OR 0.86, 95% CI 0.67 to 1.11; I2 = 8%; 12 trials, 10,485 participants). We downgraded the certainty of the evidence by three levels due to serious indirectness (diversity in outcome measurement), serious publication bias (asymmetry of results), minor imprecision (wide CIs), and minor risk of bias (blinding of participants/personnel). High-certainty evidence indicates that alternative care models result in a small but clinically unimportant improvement in pain on a 0 to 10 scale (mean difference -0.24, 95% CI -0.43 to -0.05; I2 = 68%; 36 trials, 9403 participants). Mean pain at follow-up closest to 12 months was 2.4 points on a 0 to 10 rating scale (lower score indicates less pain) with usual care compared to 2.2 points with alternative care models, a difference of 0.2 points better (95% CI 0.4 better to 0.0 better; minimal clinically important difference (MCID) 0.5 to 1.5 points). High-certainty evidence indicates that alternative care models result in a small, clinically unimportant improvement in back-related function compared with usual care (standardised mean difference -0.12, 95% CI -0.20 to -0.04; I2 = 66%; 44 trials, 13,688 participants). Mean back-related function at follow-up closest to 12 months was 6.4 points on a 0 to 24 rating scale (lower score indicates less disability) with usual care compared to 5.7 points with alternative care models, a difference of 0.7 points better (95% CI 1.2 better to 0.2 better; MCID 1.5 to 2.5 points). We are uncertain of the effect of alternative care models on adverse events compared to usual care as the certainty of the evidence was very low (OR 0.81, 95% CI 0.45 to 1.45; I2 = 43%; 10 trials, 2880 participants). We downgraded the certainty of the evidence by three levels due to serious risk of bias (blinding of participants/personnel), serious indirectness (variation in assumed risk), and serious inconsistency (substantial between-study heterogeneity).

AUTHORS' CONCLUSIONS

Compared to usual care, alternative care models for non-specific low back pain probably lead to little or no difference in the quality of care and result in small but clinically unimportant improvements in pain and back-related function. Whether alternative care models result in a difference in total adverse events compared to usual care remains unresolved.

The Movement System and Diagnosis: Are We There Yet?

In the 29th Maley lecture, Phil McClure PT, PhD, FAPTA, shares a Perspective regarding the movement system and diagnosis. Despite declarations from the House of Delegates >10 years ago, the concept of a movement system has not been widely embraced in either education or practice. In this perspective, he offers critical analysis and 3 proposals that could potentially make the concept of a movement system more relevant and meaningful. The first is to operationally define the movement system, arguing that the current definition is too vague and not operational, and therefore not meaningful. The second is to intentionally separate the movement system from any specific diagnostic classification scheme which would allow the focus to remain on movement and movement analysis. He argues that diagnostic classification schemes require a biopsychosocial framework and that movement, while important, cannot be the only consideration. The third proposal is that diagnostic schemes must be developed by clinical scientists through appropriate research guided by sound theory, not by administrative or political process. He further argues that a greater focus on determining which patients are likely to be helped by physical therapists is necessary and offered the example of developing "appropriateness criteria" as a tool toward promoting value-based care. Achieving broad consensus around these proposals could unify our professional focus and assist toward the vision of optimizing movement to enhance the human experience.

A Multidimensional Regression Model for Predicting Recurrence in Chronic Low Back Pain

BACKGROUND

Recurrence is common in chronic low back pain (CLBP). However, predicting the recurrence risk remains a challenge. The aim is to develop and validate a machine learning tool to predict the recurrence risk in patients with CLBP by using multidimensional medical information.

METHODS

This prospective cohort study consecutively enrolled 341 patients with CLBP from two hospitals between 1 January 2021 and 31 December 2021. Patients from both centres were used for model development and internal validation, employing multivariate logistic regression (MRL) along with three additional machine learning algorithms. The multidimensional model (MDM) was used to predict recurrence in the next 2 years and was compared with the widely used prognostic tool, the STarT BACK Tool (SBT). The models' performance in detecting recurrence was evaluated using several metrics, including the area under the receiver operating characteristic curve (AUC), decision curve analysis, accuracy, sensitivity and specificity.

RESULTS

A total of 131 patients (38.42%) experienced recurrence. In the MRL model, factors linked to recurrence odds included progressive lower limb weakness, anxiety, mechanical pressure test, number of previous episodes, Oswestry disability index and multifidus proton density fat fraction. For recurrence prediction, the MRL-MDM achieved an AUC of 0.813 (95% CI, 0.765-0.862), sensitivity of 85.2% and specificity of 70.2% in internal validation. In comparison, the SBT for recurrence had an AUC of 0.555 (95% CI, 0.518-0.592), sensitivity of 93.3% and specificity of 17.6%.

CONCLUSION

The MDM may predict recurrence in patients with CLBP over a 2-year period, surpassing the performance of SBT.

SIGNIFICANCE STATEMENT

This study found that the STarT BACK tool is suboptimal in predicting the 2-year recurrence of chronic low back pain (CLBP). Our proposed multidimensional machine learning model aids clinicians in identifying patients at high risk for future recurrence of CLBP and in implementing appropriate preventive measures. Given the considerable healthcare resource utilisation associated with the frequent recurrence of CLBP, our novel model provides significant assistance in addressing this issue, demonstrating substantial clinical relevance.

Are Tailored Interventions to Modifiable Psychosocial Risk Factors Effective in Reducing Pain Intensity and Disability in Low Back Pain? A Systematic Review with Meta-Analysis of Randomized Trials

OBJECTIVE: To determine whether tailored interventions based on patients' psychological profiles enhanced the outcomes of interventions in people with nonspecific low back pain, compared to usual care. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: Embase, Cochrane, Medline, Web of Science, CINAHL, and PsycINFO were searched from their inception until November 2, 2023. STUDY SELECTION CRITERIA: We included randomized clinical trials that compared psychological interventions to any alternatives without psychological components in patients with nonspecific low back pain who were stratified based on their psychological risk factors using the cutoff of the questionnaires measuring a psychological construct. DATA SYNTHESIS: The outcomes were pain intensity and disability. The revised Cochrane risk-of-bias tool for randomized trials was used to evaluate the risk of bias. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to judge certainty of evidence. RESULTS: Twenty-nine trials were included, most presenting some concerns for the risk of bias. The certainty of evidence was mostly low, with moderate to substantial heterogeneity. Using psychological stratification, individuals who received a psychological intervention (versus usual care) reported lower pain intensity at the short term (MD, -0.22; 95% confidence interval [CI]: -0.41, -0.02) and midterm (MD, -0.37; 95% CI: -0.57, -0.16). For disability, there was a larger improvement with psychological interventions versus usual care at short-term (SMD, -0.17; 95% CI: -0.32, -0.02), midterm (SMD, -0.16; 95% CI: -0.28, -0.05), and long-term (SMD, -0.17; 95% CI: -0.29, -0.04) follow-ups. CONCLUSIONS: Psychological interventions had a positive impact, although small, on reducing pain intensity and disability in patients with low back pain and psychological risk factors. J Orthop Sports Phys Ther 2025;55(2):1-20. Epub 3 January 2025. doi:10.2519/jospt.2025.12777.

[How does an intervention work?-German Version. : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0]

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

Early CRPS Is a Heterogeneous Condition: Results From a Latent Class Analysis

BACKGROUND

Complex regional pain syndrome (CRPS) is a debilitating condition characterised by significant heterogeneity. Early diagnosis is critical, but limited data exists on the condition's early stages. This study aimed to characterise (very) early CRPS patients and explore potential subgroups to enhance understanding of its mechanisms.

METHODS

A total of 113 early CRPS patients were recruited, with 89 undergoing physical assessments. Data included demographic information, work-related factors, CRPS history and clinical features, body perception disturbances, quantitative sensory testing (QST), and a visuospatial attention task.

RESULTS

QST identified deficits in detecting thermal and mechanical stimuli, alongside increased sensitivity to thermal and blunt pressure painful stimuli. Participants reported body perception disturbances similar to those of persistent CRPS. Visuospatial biases were observed in two subgroups of patients. Latent class analysis (LCA) of 85 participants, based on five clinical parameters, identified four profiles: Mild, Moderate, Body Representation Disturbance (BRD), and Pressure Allodynia CRPS. The Mild and Moderate profiles were associated with higher-intensity trauma, with the latter showing worse outcomes. BRD and Pressure Allodynia CRPS followed mild trauma but exhibited the poorest outcomes. BRD CRPS displayed significant body perception disturbances, while Pressure Allodynia CRPS presented the highest sensitivity to pressure and psychosocial risk of chronification. Neither condition duration nor skin temperature effectively distinguished subgroups.

CONCLUSIONS

These findings emphasise the heterogeneity within (very) early CRPS patients and support the absence of a minimum required duration prior to the CRPS diagnosis. Central/systemic mechanisms may play critical roles in severe cases.

SIGNIFICANCE

This study identifies distinct (very) early CRPS profiles, suggesting different pathophysiological mechanisms and challenging traditional classifications. It paves the way for improved diagnosis and tailored treatments.

ADvAnced PhysioTherapy in MuSculosKeletal Triage: Investigating prognostic factors, healthcare utilisation and clinical outcomes (ADAPT MSK) - a cohort study protocol

Background

Clinical specialist physiotherapist-led musculoskeletal triage clinics were introduced nationally in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. Evidence has shown them to be effective in reducing waiting lists, however there are currently no data on longitudinal patient outcomes following attendance at these clinics. The primary aim of this prospective, cohort study is to identify predictors of clinical outcome (pain and function) at 12-months post MSK-triage appointment. Secondary aims are to describe the clinical course of patients attending MSK triage clinics and measure self-reported use of healthcare resources up to 12 months post-MSK-triage appointment. This is a prospective cohort study.

Methods

ADvAnced PhysioTherapy in MuSculosKeletal Triage (ADAPT MSK) will recruit a cohort of 252 adults through musculoskeletal triage clinics across five secondary care sites in Ireland. The STrengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines will be adhered to for future reporting. Adults (≥ 18 years old) attending physiotherapist-led musculoskeletal triage clinics with musculoskeletal pain, who do not require surgical or consultant-led medical care will be considered for participation in this study. Participant demographics, health literacy, healthcare utilisation, and self-report questionnaires on pain, function, musculoskeletal health status, musculoskeletal risk stratification, fear of movement, and psychological distress will be obtained at baseline, with follow-ups at three, six, and 12 months. The primary outcomes are pain intensity and function. Secondary outcomes include musculoskeletal risk stratification status, musculoskeletal health status, healthcare utilisation, and work status. Descriptive statistics will be used to profile the cohort of participants and predictors of outcome will be assessed using multivariable linear regression.

Results

Results will be disseminated via peer-reviewed journal publication and presentation at national and international conferences. Engagement with a public patient involvement (PPI) panel will explore dissemination strategies for public and service user engagement.

How does an intervention work?-English Version : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

The association between screened psychological risk for disability and appropriateness of orthopedic surgery in patients with musculoskeletal disorders - data from a Swedish RCT in primary care 2009-2011

INTRODUCTION

To understand, diagnose and treat patients with musculoskeletal disorders, psychological risk factors should be assessed, and the association between psychological risk for disability and appropriateness of orthopedic surgery should be investigated.

PURPOSE

To investigate the association between screened psychological risk for disability and appropriateness of orthopedic surgery, and to examine a physiotherapist's ability to assess risk for disability in patients referred for orthopedic consultation.

METHOD

Patients (n = 192) were assessed by a physiotherapist or an orthopedic surgeon to determine the need for surgery. The Pain Belief Screening Instrument (PBSI) was used to screen for psychological risk. The physiotherapist assessed psychological risk for disability based on yellow flags. Association between PBSI risk profile and appropriateness of orthopedic surgery was analyzed using logistic regression. Sensitivity and specificity of the physiotherapist's assessment of risk was calculated using a binary classification model.

RESULTS

Orthopedic surgery was 2.28 times more likely to be considered an appropriate intervention for patients with a high PBSI risk profile (95% CI 1.09;4.78). The physiotherapist's risk assessment correctly identified 88% of those at low risk (specificity) and 32% of those at high risk for disability (sensitivity).

CONCLUSION

The findings suggest that orthopedic surgery is likely to be considered appropriate for patients with a high PBSI risk profile. The high specificity of the physiotherapist's assessment implies good awareness of psychological factors. The low sensitivity suggests a need for using a screening tool such as the PBSI, to guide management decisions.Trial registration: Clinical Trials NCT02265172, retrospectively registered June 10, 2014.

Chronic pelvic pain treatment understanding what matters: a social media survey

Abstract

Chronic pelvic pain (CPP) is a debilitating condition that reduces quality of life (QoL). In the United Kingdom, there is currently no standardised treatment pathway for women suffering from CPP. Therefore, it is essential to understand individuals' concerns regarding CPP, their treatment experiences and what they seek from treatment. To do this, we conducted a two-month social media survey focused on the UK population to explore treatment experiences and identify the factors that people consider important to managing their condition. Of 1,279 respondents, women who completed ≥50% of the questions were included (n = 864; 68%). Results suggest that many women are living with moderate-intensity CPP and experience symptoms for 6 years (average) before receiving a diagnosis. Initially, most women see general practitioners and gynaecologists (90%), with varied care beyond these providers. Using an adapted STarT Back tool, 85% of respondents were classified as medium-high risk of poor outcomes based on physical, psychosocial, and psychological risk. Thematic analysis identified that people desire treatment validation/understanding, self-management, and support to manage pain and QoL. Notably, only 26% of respondents report satisfaction with their healthcare experience, suggesting that current treatment approaches do not address these themes. In conclusion, results suggest that treatment should focus on quality-of-life improvement to enhance CPP treatment outcomes and satisfaction. Findings endorse the need for improved and standardised treatment approaches that address patients' needs.

Lay summary

CPP is persistent pain in the lower abdomen or pelvis for at least 6 months. It is common and affects approximately 1 in 6 women in the UK. To improve treatment, it is important to understand people's treatment experiences and treatment needs. We conducted a social media survey to understand how people with CPP experience treatment and what they would like from treatment. The survey was posted online for two months (May and June 2023) and received 897 responses. Responses suggested that people experience long waits before receiving help for their pain and that treatment journeys vary greatly. Overall, people reported low treatment satisfaction. People felt that effective treatment should improve pain and QoL. Themes of understanding their pain, knowing how to manage their pain and understanding treatments were identified as important. Clinicians should consider QoL and pain education as part of treatment.

Exploring mental health approaches and curriculum in physiotherapy: an Australasian perspective

BACKGROUND

Exposure to mental health problems are becoming increasingly more frequent within physiotherapy. Physiotherapists recognize the need for a biopsychosocial approach, however their knowledge, assessment, and treatment skills specific to mental health problems requires further research.

PURPOSE

To profile the level of education and perception of education that physiotherapists have acquired specific to mental health problems; and to profile an understanding of the current practice of physiotherapists specific to mental health problems.

METHODS

An online survey addressed the aims of the study and collected data from physiotherapists in Australia and New Zealand (open between 20th of October 2022 to the 20th of March 2023).

RESULTS

139 respondents were included in the analysis. Physiotherapists had a perception that a significantly greater amount of coursework related to mental health needed to be included within their initial degree compared to what they received (mean difference of 20.0%, 95% CI: 17.5 to 22.5). This trend was evident irrespective of the degree level or the year of graduation. Higher perceived knowledge of anxiety (MD of 11.4, p = 0.001, ES: 0.5) and depression (MD of 11.8, p = 0.001, ES: 0.5) was evident in outpatient care physiotherapists. Lack of perceived knowledge is a reason for whether an assessment or treatment strategy is used with patients experiencing a mental health problem. Motivational interviewing and mindfulness were the most frequently used psychologically based techniques.

CONCLUSION

This study reveals the need to increase the amount of mental health and psychologically based techniques within Physiotherapy curriculum.

Assessment of a manual therapy and acupressure method as a treatment of nonspecific low back pain: A prospective, observational and non-interventional cohort study

The first-line treatment for nonspecific low back pain (LBP) relief is physical exercise; however, there is no uniformity in recommendations regarding the type of exercise, and physicians predominantly prescribe pharmacological treatments. This creates a treatment gap in non-pharmacological management of LBP. Preliminary data suggest that manual therapy and acupressure could be relevant therapeutic options. The primary objective of this study was to describe the evolution of pain in patients with nonspecific LBP persisting for at least 4 weeks who received 2 treatment sessions combining manual therapy with acupressure (Biokinergie® method) as part of their routine management. In this prospective, observational, and non-interventional study, participants were monitored on the days of manual therapy session delivery (initial visit on Day 0 and follow-up visit on Day 21). Follow-up assessments occurred 3 days and 3 weeks post-therapy sessions. A total of 114 participants suffering from LBP for a median duration of 11.9 weeks were enrolled from May 2021 to May 2023. The intensity of average pain experienced over a 24-hour period was significantly reduced on Day 24 (-36.0 ± 27.2 mm on a visual analog scale of 100 mm, P < .001), with 82 (75.2%) participants reporting a decrease of at least 20 mm. Participants reported significant reductions in pain (-25.9 ± 23.9 mm on Day 3, -29.7 ± 26.7 mm on Day 21, and -40.9 ± 28.3 mm on Day 42, P < .001) and functional disability (Roland-Morris Disability Questionnaire score: -5.4 ± 0.4 points on Day 21 and -7.4 ± 0.4 points on Day 42, P < .001). This was associated with an improved Dallas Pain Questionnaire score, indicating a reduced impact of LBP on daily activities (-27.2 ± 2.0% on Day 21 and -35.8 ± 2.0% on Day 42, P < .001). Posttreatment, most participants (86.3%) reported reduced analgesic intake compared to baseline, and 83.3% were very satisfied with the therapy. A significant and clinically relevant reduction in lumbar pain was observed after 2 sessions of manual therapy combined with acupressure, paving the way for future clinical research.

Stratified health care for low back pain using the STarT Back approach: holy grail or doomed to fail?

ABSTRACT

There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.

Effectiveness and Stakeholder Views of Community-Based Allied Health on Acute Care Utilization: A Mixed Methods Review

The aim of this mixed methods systematic review was to synthesize contemporary evidence on effectiveness of community-based allied health (AH) services on acute care utilizations and views from relevant stakeholders. An a priori protocol was registered with PROSPERO [CRD42023437013]. Inclusion criteria were: (a) stand-alone interventions led by practitioners/graduates from one or more target AH professions (audiology, exercise physiology, diabetes educator, nutrition and dietetics, occupational therapy, physiotherapy, podiatry, psychology, social work, and speech pathology); (b) examined acute care utilization-related outcomes with/without perceptions of relevant stakeholders; and (c) published after 2010 and in English. Eligible studies were identified from: (a) bibliographic databases (MEDLINE, Embase, EmCare, PsycINFO, CINAHL complete, and the Cochrane Library) (September 19, 2023); (b) online databases (ProQuest Central and ProQuest Dissertations & Theses Global) and theses repository (Trove) (September 20, 2023); (c) Google and Google Scholar (October 17-18, 2023); and (d) citation searching. A modified version of McMaster Critical Appraisal Tools and McGill Mixed Methods Appraisal Tool were used to assess methodological quality. Data synthesis was through convergent segregated approach. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. There were 67 included papers. The integrated quantitative and qualitative findings demonstrated mixed evidence, likely influenced by the heterogeneity of the evidence base, for the effectiveness of AH services on acute care utilizations. Patients and their carers were largely positive about these services, highlighting opportunities to build on these experiences. The certainty of evidence for patient-important outcomes was however "very low", emphasizing cautious interpretation. The findings of this review shed light on the breadth and scope of AH in the community sector, and its potential impact on the acute sector. Further investment in, and ongoing research on, community-based AH can strengthen primary healthcare and relieve pressure on the acute sector.

Physiotherapists as first-contact practitioners for patients with low back pain in French primary care: a pragmatic cluster randomised controlled trial

BACKGROUND

A new model of care enables French physiotherapists (PT) working in collaboration with family physicians (FP) to expand their usual scope of practice for patients with acute low back pain (LBP). The aim of our study is to evaluate the impact of this new first-contact physiotherapy (FCP) advanced practice model compared to usual FP care.

METHODS

A multicentre pragmatic non-inferiority cluster randomised controlled trial (RCT) has been conducted in six multidisciplinary primary healthcare centres in France. Patients from 20 to 55 years old with acute LBP consulted either the PT or the FP. PT independently assessed and managed patients including medication prescription. The primary outcome measure was disability at six weeks (Roland Morris Disability Questionnaire, range 0-24). Secondary outcomes include pain, risk disability prognosis, satisfaction with care, healthcare resources use and wait times. Data were collected at baseline, six and twelve weeks. Outcomes across arms were compared using mixed models regression analysis. Except for non-inferiority analysis of the primary outcome measure, other analyses were performed with a two-sided significance level of 0.05.

RESULTS

Sixty patients were recruited (PT: 32, FP: 28). The adjusted mean difference between groups for disability at 6 weeks was 0.39 in favour of the FP group (95%CI: -2.03; 2.81, p = 0.753). Considering a 5 points minimal clinically important difference, the FCP-led model of care was not inferior to usual FP care for the primary outcome. There was no statistically significant difference between groups in disability at 3 months and pain at 6 weeks and 3 months. PTs prescribed significantly less medications than FPs (p < 0.001). No statistically significant difference was found for other healthcare resource use outcomes, patients' satisfaction and wait times.

CONCLUSION

This is the first RCT to evaluate the impact of a FCP advanced practice model of care including medical delegated acts in a primary care setting. Our results suggest that the FCP-led model of care is not inferior to usual FP care regarding disability at 6 weeks. The FCP model could result in possible benefits in terms of healthcare resources use. Further adequate powered studies with larger sample size are needed to draw stronger conclusions.

TRIAL REGISTRATION

The study has been registered in ClinicalTrials.gov (NCT05200533) on the 20th of January 2022.

A scoping review on implementation processes and outcomes of models of care for low back pain in primary healthcare

BACKGROUND

To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare.

METHODS

MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches.

RESULTS

Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes.

CONCLUSIONS

The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare.

REGISTRATION

Open Science Framework Registries ( https://osf.io/rsd8x ).

Research hotspots and frontiers in non-specific low back pain: a bibliometric analysis

Background

Extensive research has been conducted worldwide on non-specific low back pain (NSLBP), some researchers published a bibliometric analysis of NSLBP in 2020, but there have been no supplements or updates since then. Therefore, this study aimed to analyze the research hotspots and frontiers in NSLBP over the last decade.

Methods

Primary sources on NSLBP were obtained from the Web of Science Core Collection database from 2014 to 2023. CiteSpace V6.2. R7 (64-bit) and VOSviewer 1.6.19 software were used to analyze the number and centrality of journals, countries, institutions, authors, references, and keywords, and the functions of co-occurrence and clustering were applied to draw a visual knowledge map.

Results

In the past decade, the annual publication volume of studies on NSLBP has shown an overall upward trend year by year, with obvious temporal stages and great development potential. In total, 2,103 articles contained six types of literature, with the highest proportion being original research articles (1,633 articles, 77.65%), published in 200 journals. BMC Musculoskeletal Discourses (90 articles, 4.28%) had the highest number of publications, and the British Medical Journal had the highest impact factor (105.7). Furthermore, the United States of America (329 articles, 15.64%) had the highest publication volume, the University of Sydney (139 articles, 6.61%) was the research institution with the highest production, Maher, Chris G (36 articles, 1.71%) was the author with the most published articles, and Hoy, D (571 articles, 27.15%) was the most frequently cited author. The most cited of articles is "Non-specific low back pain" published in the LANCET, with 1,256 citations.

Conclusion

This article summarizes the current research status of NSLBP and predicts future research hotspots and frontiers. In recent years, adolescents have become a high-risk group for NSLBP. Pain neuroscience education, motor control, spinal manipulative therapy, and acupuncture are effective means to treat NSLBP. Biomechanics and trunk muscles as entry points are effective ideas for the treatment of NSLBP pain. Furthermore, anxiety, neck pain, non-specific musculoskeletal pain, fibromyalgia, and musculoskeletal disorders are diseases that are closely related to NSLBP. In the future, attention should be paid to the design of research plans, increasing the research intensity of randomized controlled trials, strengthening follow-up, and the timely updating of guidelines, which will result in higher quality and high-level scientific evidence for research on NSLBP.

Is One Enough? The Effectiveness of a Single Session of Education and Exercise Compared to Multiple Sessions of a Multimodal Physiotherapy Intervention for Adults With Spinal Disorders in an Advanced Practice Physiotherapy Model of Care: A Randomized Controlled Trial

OBJECTIVE: To assess the effectiveness of a single session of education and exercise compared with multiple sessions of a multimodal physiotherapy intervention for adults with spinal disorders in an advanced practice physiotherapy specialized spine model of care. DESIGN: Pragmatic randomized controlled trial. METHODS: We randomized patients with spinal disorders, who were referred for a spinal surgery consultation and triaged as nonsurgical cases by an advanced practice physiotherapist, to a single session of education and prescription of an exercise program (n = 52) or multiple sessions (6 in total) of a multimodal physiotherapy intervention (n = 54). The primary outcomes were the short form Brief Pain Inventory pain severity scale (BPI-S) and the Brief Pain Inventory pain interference scale (BPI-I), and secondary outcomes included disability, quality of life, catastrophization, and satisfaction. Linear mixed models were used to assess differences between groups across time points at 6, 12, and 26 weeks. RESULTS: There were no significant between-group differences on the BPI-S and only a significant improvement at 6 weeks on the BPI-I in the multiple-session group (mean difference: -0.96/10; 95% CI, -1.87 to -0.05). There were no other statistically significant differences between groups, except for satisfaction where participants in the multiple-session group reported statistically significantly greater satisfaction on the 9-item Visit-Specific Satisfaction Questionnaire and the MedRisk questionnaire. Both groups saw significant improvements over time on all outcomes except for the BPI-S. CONCLUSION: Adding supervised multimodal physiotherapy sessions did not result in better clinical outcomes when compared to a single session of education and exercise. Patients were more satisfied with the multiple-session approach. J Orthop Sports Phys Ther 2024;54(10):1-13. Epub 9 September 2024. doi:10.2519/jospt.2024.12618.

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Shoulder Symptom Trajectories Over Four Years: Data From a Longitudinal Study on Osteoarthritis

OBJECTIVE

Limited data exist on the natural history of shoulder symptoms. We aimed to describe longitudinal patterns of shoulder symptoms and determine risk factors for incidence and persistence.

METHODS

Data from Osteoarthritis Initiative participants observed annually for four years were used to describe shoulder symptom (yes/no, side) incidence and prevalence using descriptive analyses. Regression analyses investigated the association among three shoulder symptoms outcomes (persistent, incident, and intermittent) and clinical factors. Latent class growth analysis (LCGA) identified trajectories in those reporting pain at one or more time point.

RESULTS

In total, 4,796 participants (58% women, mean age 61.2 years) were included. Baseline shoulder symptom prevalence was 22%; 32% of these reported bilateral symptoms. In those reporting right symptoms, 260 of 1,886 (14%) had persistent symptoms. Those with persistent symptoms had worse baseline and four-year clinical status (poorer function, mental health, and quality of life). In regression analysis, persistent symptoms were associated with sleep disturbance (adjusted odds ratio [aOR] 1.97, 95% confidence interval [95% CI] 1.49-2.62), work absenteeism (aOR 2.16, 95% CI 1.38-2.62), lower limb weakness (aOR 1.76, 95% CI 1.37-2.27), multiple-site joint symptoms (≥3 joints excluding shoulders) (aOR 4.90, 95% CI 2.79-8.58) and White race (aOR 1.39, 95% CI 1.04-1.88). Lower limb weakness was also associated with incident symptoms; no variables were associated with intermittent symptoms. LCGA identified two trajectories: the trajectory with high probability for symptoms (9% of LCGA analysis cohort) showed similar relationships to clinical variables as in the persistent symptoms group.

CONCLUSION

In this large, four-year study, persistent shoulder symptoms were common and associated with worse clinical outcomes. At least one risk factor for incident symptoms is modifiable.

Characterizing Acute Low Back Pain in a Community-Based Cohort: Results from a Feasibility Cohort Study

Introduction

Acute low back pain (LBP) is a common experience; however, the associated pain severity, pain frequency, and characteristics of individuals with acute LBP in community settings have yet to be well understood. In this manuscript, two acute-LBP severity categorization definitions were developed: 1) pain impact frequency (impact-based) and 2) pain intensity (intensity-based) severity categories. The purpose of this manuscript is to describe and then compare these acute-LBP severity groups in the following characteristics: 1) sociodemographic, 2) general and physical health, and 3) psychological using a feasibility cohort study.

Methods

This cross-sectional study used baseline data from 131 community-based participants with acute LBP (<4 weeks duration before screening and ≥30 pain-free days before acute LBP onset). Descriptive associations were calculated as prevalence ratios of categorical variables and Hedges' g for continuous variables.

Results

Our analyses identified several large associations for impact-based and intensity-based categories with global mental health, global physical health, STarT Back Screening Tool risk category, and general health. Larger associations were found with social constructs (racially and ethnically minoritized, performance of social roles, and isolation) when using the intensity-based versus impact-based categorization.

Discussion

This study adds to the literature by providing standard ways to characterize community-based individuals experiencing acute-LBP. The robust differences observed between these categorization approaches suggest that how we define acute-LBP severity is consequential; these different approaches may be used to improve the early identification of factors potentially contributing to the development of chronic-LBP.

What Gets Measured Gets Managed: A Scoping Review of Musculoskeletal Research Conducted Within Practice-Based Research Networks

ABSTRACT

Musculoskeletal conditions are often managed in primary care settings. To facilitate research and healthcare quality, practice-based research networks offer sustained collaborations between clinicians and researchers. A scoping review was conducted to describe characteristics of practice-based research networks used for musculoskeletal research and musculoskeletal research conducted through practice-based research networks. Practice-based research networks were identified from 1) musculoskeletal-studies identified in OVID Medline, CINAHL, and Embase databases from inception to 5 February 2023 and in ClinicalTrials.gov and 2) from practice-based research network registries and websites. Among active musculoskeletal-focused practice-based research networks (i.e., currently recruiting and conducting research), an assessment of practice-based research network research good practices was performed. After screening 3025 records, 85 studies from 46 unique practice-based research networks met our eligibility criteria. Common conditions studied were low back pain (28%), musculoskeletal conditions not otherwise specified (25%), and osteoarthritis (19%). Thirty-two practice-based research networks (70%) were deemed to be active. Among active musculoskeletal-focused practice-based research networks, best practice data management information was retrievable for most (53%). Because of the scarcity of publicly available information, a large proportion of practice-based research network research good practice items was not assessable. Practice-based research networks have provided an avenue to assess clinical practice and patient outcomes related to musculoskeletal conditions. Further work to increase the transparency of musculoskeletal practice-based research network research practices is warranted.

Does risk stratification with a matched treatment pathway improve clinical outcomes for adults with acute back pain? A systematic review and meta-analysis

BACKGROUND

Risk stratification is an approach which has been recommended across a number of international guidelines for the management of back pain.

OBJECTIVE

To assess whether the use of risk stratification with a matched treatment pathway improves clinical outcomes, when compared with usual care or other interventions, in adults with acute back pain.

METHODS

A comprehensive search was conducted of the databases Medline, Embase, PEDro, CINAHL and Cochrane Library in November 2022. Studies of adults with back pain of less than 3 months' duration and who had been stratified according to their level of risk of a poor functional outcome and provided with a treatment matched to their level of risk were included. Participants with specific and/or serious spinal pathologies were excluded.

RESULTS

Five trials involving 3519 participants were included. Meta-analysis found very-low certainty evidence that the use of a risk stratification approach with matched treatment may lead to a very small reduction in pain levels at 3-6 months compared with usual care (MD -0.62, 95 % CI -0.88, -0.36). These results did not achieve clinical significance. No difference was found for the use of risk stratification compared to usual care for disability (MD -1.52, 95 % CI -4.15, 1.11).

CONCLUSION

The use of risk stratification with matched treatment may be just as worthwhile as usual care for acute back pain, however the evidence is very uncertain. Further high quality research is required to confirm whether risk stratification is a useful approach for this population.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42022379987.

Effectiveness of digital Cognitive-Behavioural Therapy for Insomnia in patients with musculoskeletal complaints and insomnia in primary care physiotherapy: study protocol for a randomised controlled trial

INTRODUCTION

Insomnia is prevalent among patients visiting physiotherapists due to musculoskeletal complaints and associated with poorer pain prognosis. Cognitive-Behavioural Therapy for Insomnia (CBT-I) may be effective for improving sleep quality and pain-related outcomes in these patients, but its availability and utility are limited in daily physiotherapy practice. The aim of this randomised controlled trial (RCT) is to evaluate the effectiveness of digital CBT-I in addition to usual treatment in patients with chronic musculoskeletal complaints and insomnia, compared with usual treatment only.

METHODS AND ANALYSIS

In this RCT, eligible and consenting participants will be randomised (1:1 ratio) to one of two interventions: (1) digital CBT-I adjunct to physiotherapy treatment or (2) usual physiotherapy treatment. Patients with musculoskeletal complaints and insomnia visiting a physiotherapist in Norway will be invited to participate in the study. We aim to include 188 participants to detect a difference in the primary outcome. Outcome variables will be assessed at baseline (prior to randomisation) and at 6-week, 3-month, 6-month and 12-month follow-up. The primary outcome is between-group difference in insomnia severity, assessed with the Insomnia Severity Index (0-28 points) at 3 months. Secondary outcomes include between-group differences in pain intensity, physical function, work ability, health-related quality of life, mental distress, and self-reported use of sleep and pain medication. Exploratory analyses will identify patient characteristics influencing the effect of the digital intervention.

ETHICS AND DISSEMINATION

This trial is approved by the Regional Committee for Medical and Health Research Ethics in Central Norway (Ref. 2023/533381). The results of the trial will be published in peer-review journals and disseminated at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN91221906.

Cost-Effectiveness of a Multi-faceted Workplace Intervention to Reduce Musculoskeletal Pain in Nursing Staff: A Cluster-Randomized Controlled Trial (INTEVAL_Spain)

PURPOSE

To evaluate the cost-effectiveness of a multifaceted workplace intervention to reduce musculoskeletal pain (MSP) in nursing staff.

METHODS

The study was a 1-year cluster-randomized controlled trial. The intervention combined participatory ergonomics, health promotion, and case management. The control group received usual care. Societal and health system perspectives were used. Costs included direct health and indirect costs. The effects were MSP and quality-adjusted life years (QALYs). MSP was measured using the Standardized Nordic Questionnaire at baseline and 6- and 12-month follow-up. QALYs were measured using the EuroQol-5D-3L at 6- and 12-month follow-up. Incremental costs and QALYs were modelled using generalized linear models. MSP was analysed through generalized logistic models. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness planes and acceptability curves were constructed.

RESULTS

Total mean costs per person were €614 and €216 for the intervention and control group, respectively, with a societal perspective. The intervention mean cost was €38/person. From the societal perspective, the ICER showed that overall additional €68 (€9 from a health system perspective) were required to achieve 1-extra-percentage-point reduction of MSP. ICERs were €34 from the societal and €4 from the health system perspectives for neck, shoulders and upper back pain; €53 and €7 for low back; €179 and €23 for hands; €39 and €5 for legs; €115 and €14 for the knees; €36 and €5 for feet For MSP in the elbows. For participants with pain in the elbow, and for QALYs, the ICER showed that the intervention group was dominated by the control group.

CONCLUSION

This intervention was not cost-effective in terms of QALYs. However, in terms of MSP, with a willingness to pay of €100, the probability of the intervention being cost-effective was around 90%. Further studies incorporating our recommendations are needed to confirm these findings.

STUDY REGISTRATION

ISRCTN15780649, retrospectively registered.

Health screening clinic to reduce absenteeism and presenteeism among NHS Staff: eTHOS a pilot RCT

Background

Staff sickness absenteeism and presenteeism (attending work while unwell) incur high costs to the NHS, are associated with adverse patient outcomes and have been exacerbated by the COVID-19 pandemic. The main causes are mental and musculoskeletal ill health with cardiovascular risk factors common.

Objectives

To undertake a feasibility study to inform the design of a definitive randomised controlled trial of the effectiveness and cost effectiveness of a health screening clinic in reducing absenteeism and presenteeism amongst the National Health Service staff.

Design

Individually randomised controlled pilot trial of the staff health screening clinic compared with usual care, including qualitative process evaluation.

Setting

Four United Kingdom National Health Service hospitals from two urban and one rural Trust.

Participants

Hospital employees who had not previously attended a pilot health screening clinic at Queen Elizabeth Hospital Birmingham.

Interventions

Nurse-led staff health screening clinic with assessment for musculoskeletal health (STarT musculoskeletal; STarT Back), mental health (patient health questionnaire-9; generalised anxiety disorder questionnaire-7) and cardiovascular health (NHS health check if aged ≥ 40, lifestyle check if < 40 years). Screen positives were given advice and/or referral to services according to UK guidelines.

Main outcome measures

The three coprimary outcomes were recruitment, referrals and attendance at referred services. These formed stop/go criteria when considered together. If any of these values fell into the 'amber' zone, then the trial would require modifications to proceed to full trial. If all were 'red', then the trial would be considered unfeasible. Secondary outcomes collected to inform the design of the definitive randomised controlled trial included: generalisability, screening results, individual referrals required/attended, health behaviours, acceptability/feasibility of processes, indication of contamination and costs. Outcomes related to the definitive trial included self-reported and employee records of absenteeism with reasons. Process evaluation included interviews with participants, intervention delivery staff and service providers. Descriptive statistics were presented and framework analysis conducted for qualitative data. Due to the COVID-19 pandemic, outcomes were captured up to 6 months only.

Results

Three hundred and fourteen participants were consented (236 randomised), the majority within 4 months. The recruitment rate of 314/3788 (8.3%) invited was lower than anticipated (meeting red for this criteria), but screening identified that 57/118 (48.3%) randomised were eligible for referral to either general practitioner (81%), mental health (18%) and/or physiotherapy services (30%) (green). Early trial closure precluded determination of attendance at referrals, but 31.6% of those eligible reported intending to attend (amber). Fifty-one of the 80 (63.75%) planned qualitative interviews were conducted. Quantitative and qualitative data from the process evaluation indicated that the electronic database-driven screening intervention and data collection were efficient, promoting good fidelity, although needing more personalisation at times. Recruitment and delivery of the full trial would benefit from a longer development period to better understand local context, develop effective strategies for engaging with underserved groups, provide longer training and better integration with referral services. Delivery of the pilot was limited by the impact of COVID-19 with staff redeployment, COVID-research prioritisation and reduced availability of community and in-house referral services. While recruitment was rapid, it did not fully represent ethnic minority groups and truncated follow-up due to funding limitations prevented full assessment of attendance at recommended services and secondary outcomes.

Conclusions

There is both a clinical need (evidenced by 48% screened eligible for a referral) and perceived benefit (data from the qualitative interviews) for this National Health Service staff health screening clinic. The three stop/go criteria were red, green and amber; therefore, the Trial Oversight Committee recommended that a full-scale trial should proceed, but with modifications to adapt to local context and adopt processes to engage better with underserved communities.

Trial registration

This trial is registered as ISRCTN10237475.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/42/42) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 23. See the NIHR Funding and Awards website for further award information.

General and Pain-Associated Psychological Distress Phenotypes Among Patients With Low Back Pain in the Military Health System

OBJECTIVE

The primary objective was to describe rates of general and pain-related psychological distress for individuals with low back pain (LBP) in the Military Health System (MHS). We identified common phenotypes defined by rates of general and pain-related psychological distress and compared phenotypes on their level of pain interference, physical function, anxiety, and depression.

METHODS

We created a cohort from two completed trials assessing nonpharmacological treatment for LBP in the MHS (n = 510 total). The Optimal Screening for Prediction of Referral and Outcome Yellow Flag assessment tool identified the presence of 11 different yellow flags. Latent class analysis (LCA) used yellow flag indicators to identify common psychological phenotypes. We then compared Patient-Reported Outcomes Measurement Information Systems measures of pain interference, physical function, sleep disturbance, depression, and anxiety across phenotypes.

RESULTS

LCA identified five phenotypes (percentage of the sample): low distress (32%), high distress (27%), poor pain coping and low self-efficacy (18%), low self-efficacy and acceptance (14%), and poor pain coping (10%). Highly distressed phenotypes reported higher levels of pain interference, sleep disturbance, depression, and anxiety than those with other phenotypes, whereas the low distress phenotype had significantly lower pain interference and higher physical function scores than those characterized by all other phenotypes.

CONCLUSION

These phenotypes provide opportunities for clinicians and researchers to develop novel LBP treatment pathways tailored to patients with different profiles of psychological distress. Future work is needed to validate their predictive capabilities for clinical outcomes.

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Best Practices in Documenting and Coding High-Value Care in Workers' Compensation Encounters-ACOEM Guidance Statement

ABSTRACT

Workers' compensation outpatient care requires attention to causation, functional assessment, work disability prevention, and return-to-work planning, elements not usually addressed in other types of outpatient encounters. Because these elements of care deviate from the usual pattern of ambulatory services, providers of workers' compensation care have faced challenges in billing and auditing practices resulting in underpayment when providing high-value care based on evidence-based guidelines. Recent changes in Centers for Medicare & Medicaid Services rules on documentation requirements for coding outpatient evaluation and management encounters offer an opportunity for occupational health clinicians to be paid appropriately for care that follows occupational medicine practice guidelines. There remains a need to define the elements of documentation that should be expected in delivering high-value workers' compensation care. This article provides guidance for documenting high-value workers' compensation care.