Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial

Association of back pain with all-cause and cause-specific mortality among older men: a cohort study

OBJECTIVE

We evaluated whether more severe back pain phenotypes-persistent, frequent, or disabling back pain-are associated with higher mortality rate among older men.

METHODS

In this secondary analysis of a prospective cohort, the Osteoporotic Fractures in Men (MrOS) study, we evaluated mortality rates by back pain phenotype among 5215 older community-dwelling men (mean age, 73 years, SD = 5.6) from 6 sites in the United States. The primary back pain measure used baseline and Year 5 back pain questionnaire data to characterize participants as having no back pain, nonpersistent back pain, infrequent persistent back pain, or frequent persistent back pain. Secondary measures of back pain from the Year 5 questionnaire included disabling back pain phenotypes. The main outcomes measured were all-cause and cause-specific death.

RESULTS

After the Year 5 exam, during up to 18 years of follow-up (mean follow-up = 10.3 years), there were 3513 deaths (1218 cardiovascular, 764 cancer, 1531 other). A higher proportion of men with frequent persistent back pain versus no back pain died (78% versus 69%; sociodemographic-adjusted HR = 1.27, 95% CI = 1.11-1.45). No association was evident after further adjustment for health-related factors, such as self-reported general health and comorbid chronic health conditions (fully adjusted HR = 1.00; 95% CI = 0.86-1.15). Results were similar for cardiovascular deaths and other deaths, but we observed no association of back pain with cancer deaths. Secondary back pain measures, including back-related disability, were associated with increased mortality risk that remained statistically significant in fully adjusted models.

CONCLUSION

Although frequent persistent back pain was not independently associated with risk of death in older men, additional secondary disabling back pain phenotypes were independently associated with increased mortality rate. Future investigations should evaluate whether improvements in disabling back pain affect general health and well-being or risk of death.

Italian versions of the Neurophysiology of Pain Questionnaire (NPQ): psychometric properties and an investigation on the understanding of pain neurophysiology in physical therapists

OBJECTIVES

The Neurophysiology of Pain Questionnaire (NPQ) is widely used to assess pain knowledge among clinicians and patients with pain, but an Italian version is not available. This study aimed to translate and cross-culturally adapt the NPQ into Italian, to test its psychometric properties, to assess the knowledge of Italian physical therapists (PTs) on pain, and to evaluate which characteristics are associated with pain knowledge.

METHODS

The NPQ was translated into Italian, integrated with some additional questions (IT-NPQ-New), and sent by email via the Italian Association of Physiotherapy newsletter. Rasch analysis (RA) was used to test the psychometric properties of the Italian versions. Multivariable regression analyses were used to check for associations between participants' characteristics and their NPQ scores.

RESULTS

A sample of 753 PTs completed the survey. RA of the NPQ-19 and IT-NPQ-New revealed that 10 (IT-NPQ-10) and 18 (IT-NPQ-18) items fit the model. Both questionnaires showed good psychometric properties. The overall median score among Italian PTs was 6.0 [5.0-7.0] and 11.0 [9.0-13.0] points for the IT-NPQ-10 and the IT-NPQ-18, respectively. These scores were statistically different among groups according to gender, age, years of professional activity, post-graduate specialization and days attended of targeted pain courses, with the latter being the most influential variable.

CONCLUSIONS

Italian PTs now dispose of two tools to assess their basic knowledge related to pain science. Our study also showed that pain knowledge among Italian PTs needs improvement, especially considering recent biopsychosocial approaches to pain.

Implementation of back to living well, a community-based program for the tertiary prevention of low back pain: a study protocol

BACKGROUND

The current literature supports the effectiveness of exercise, education, and self-management interventions for the long-term management of persistent low back pain. However, there is significant uncertainty about the implementation of interventions related to barriers, facilitators, and patient's preferences. This study will evaluate the Back to Living Well program implementation from a participant and organizational perspective. More specifically we address the following objectives: 1) identify program barriers and facilitators from participants' perspectives, 2) identify factors related to program, personal and contextual factors that contribute to negative and positive outcomes, and outcome trajectories, 3) identify factors influencing participants' selection of an in-person or e-health program, and 4) evaluate program specific barriers and facilitators from the organization and care delivery perspectives.

METHODS

This study will utilize a mixed-method convergent design including a longitudinal cohort strand and a longitudinal qualitative interview strand. The RE-AIM framework will be used to assess program implementation. Participants (n = 90, 1:1: in person or virtual) who choose to register in the program as well as staff (n = 10 to 15) involved in the delivery of the program will be invited to participate. Participants will participate in a 12-week physical activity, education, and self-management program. Implementation outcomes will be measured at 3-, 6-, 12-months, and six months after the end of the follow-ups. Interview scripts and directed content analysis will be constructed based on the Theoretical Domains Framework and the Neuromatrix Model of Pain, Theoretical Domains Framework. Staff interviews will be constructed and analyzed using the Consolidated Framework for Implementation Research. Participants will also complete pain, disability, quality of life and psychological questionnaires, wear an activity tracker at all time points, and complete weekly pain and activity limitation questions using a mobile application.

DISCUSSION

The study results will provide evidence to inform potential future implementation of the program. An effective, appropriately targeted, and well implemented exercise program for the long-term management (i.e., tertiary prevention) of LBP could minimize the burden of the condition on patients, the health care system and society.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05929846. This (Registration Date: July 3 2023) study has been approved by the Hamilton Integrated Research Ethics Board Project ID#15,354.

Assessing the impact of health-care access on the severity of low back pain by country: a case study within the GBD framework

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is key for policy making. Low back pain is the leading cause of disability in terms of years lived with disability (YLDs). Due to sparse data, a current limitation of GDB is that a uniform severity distribution is presumed based on 12-Item Short Form Health Survey scores derived from US Medical Expenditure Panel Surveys (MEPS). We present a novel approach to estimate the effect of exposure to health interventions on the severity of low back pain by country and over time.

METHODS

We extracted treatment effects for ten low back pain interventions from the Cochrane Database, combining these with coverage data from the MEPS to estimate the hypothetical severity in the absence of treatment in the USA. Severity across countries was then graded using the Health Access and Quality Index, allowing estimates of averted and avoidable burden under various treatment scenarios.

FINDINGS

We included 210 trials from 36 Cochrane systematic reviews in the network analysis. The pooled effect sizes (measured as a standardised mean difference) for the most effective intervention classes were -0·460 (95% uncertainty interval -0·606 to -0·309) for a combination of psychological and physical interventions and -0·366 (-0·525 to -0·207) for surgery. Globally, access to treatment averted an estimated 17·6% (14·8 to 23·8) of the low back pain burden in 2020. If all countries had provided access to treatment at a level estimated for Iceland with the highest Health Access and Quality Index score, an extra 9·1% (6·4 to 11·2) of the burden of low back pain could be avoided. Even with full coverage of optimal treatment, a large proportion (65·9% [56·9 to 70·4]) of the low back pain burden is unavoidable.

INTERPRETATION

This methodology fills an important shortcoming in the GBD by accounting for low back pain severity variations over time and between countries. Assumptions of unequal treatment access increased YLD estimates in resource-poor settings, with a modest decrease in countries with higher Health Access and Quality Index scores. Nonetheless, the large proportion of unavoidable burden indicates poor intervention efficacy. This method, applicable to other GBD conditions, provides policy makers with insights into health gains from improved treatment and underscores the importance of investing in research for new interventions.

FUNDING

Bill and Melinda Gates Foundation and Queensland Health.

Therapeutic Patient Education as Part of the Physiotherapy Management of Adults with Headache: A Scoping Review

PURPOSE OF REVIEW

Physiotherapy interventions for headache mostly include exercise and manual therapy. Yet, the complex nature of headache, sometimes characterized by symptoms of facilitated central pain mechanisms, demands an individualized approach in which therapeutic patient education could be supportive. This scoping review aimed to summarize the position of therapeutic patient education within the physiotherapy management of adults with headache. PubMed, EMBASE, Web of Science, and Scopus were searched. The search-query comprised terminology relating to "headache", "education", and "physiotherapy". Eligibility criteria were: adults with headache, interventions including education within the domain of physiotherapy, reviews, clinical trials, cohort, case report, case-control studies.

RECENT FINDINGS

Eleven publications were included from the 281 retrieved publications. These publications were clinical trials (n = 4), reviews (n = 4), case-reports (n = 2), and a guideline (n = 1). Type of headaches studied were migraine (n = 3), post-traumatic headache (n = 2), tension-type headache (n = 2), cervicogenic headache (n = 1), primary headaches (n = 1), chronic daily headache (n = 1), and mixed migraine-cervicogenic headache (n = 1). Education seems an umbrella-term for postural education, lifestyle advice, and pain education. Three themes emerged across the publications: handling headache triggers (migraine, post-traumatic headache), promoting active lifestyle (post-traumatic headache, chronic daily headache, migraine), evaluating posture (post-traumatic headache, chronic daily headache, tension-type headache, cervicogenic headache). All publications recommended education in the management of headache. Only one (of the 11 included) publication described the educational program and determined its efficacy. Based on this scoping review, therapeutic patient education seems supported within physiotherapy management of headache. However, it is unclear how such education is tailored to the specific needs of the individual, the headache subtype, or when it should be added to physiotherapy management of headache.

Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

Medical App Treatment of Non-Specific Low Back Pain in the 12-month Cluster-Randomized Controlled Trial Rise-uP: Where Clinical Superiority Meets Cost Savings

Purpose

Non-specific low back pain (NLBP) exerts a profound impact on global health and economics. In the era of Web 3.0, digital therapeutics offer the potential to improve NLBP management. The Rise-uP trial introduces a digitally anchored, general practitioner (GP)-focused back pain management approach with the Kaia back pain app as the key intervention. Here, we present the 12-months evaluation of the Rise-uP trial including clinical and economic outcomes, patient satisfaction and behavioral tracking analysis.

Methods

The cluster-randomized controlled study (registration number: DRKS00015048) enrolled 1237 patients, with 930 receiving treatment according to the Rise-uP approach and 307 subjected to standard of care treatment. Assessments of pain, psychological state, functional capacity, and well-being (patient-reported outcome measures; PROMs) were collected at baseline, and at 3-, 6-, and 12-months follow-up intervals. Health insurance partners AOK, DAK, and BARMER provided individual healthcare cost data. An artificial intelligence (AI)-driven behavioral tracking analysis identified distinct app usage clusters that presented all with about the same clinical outcome. Patient satisfaction (patient-reported experience measures; PREMs) was captured at the end of the trial.

Results

Intention-to-treat (ITT) analysis demonstrated that the Rise-uP group experienced significantly greater pain reduction at 12 months compared to the control group (IG: -46% vs CG: -24%; p < 0.001) with only the Rise-uP group achieving a pain reduction that was clinically meaningful. Improvements in all other PROMs were notably superior in patients of the Rise-uP group. The AI analysis of app usage discerned four usage clusters. Short- to long-term usage, all produced about the same level of pain reduction. Cost-effectiveness analysis indicated a substantial economic benefit for Rise-uP.

Conclusion

The Rise-uP approach with a medical multimodal back pain app as the central element of digital treatment demonstrates both, clinical and economic superiority compared to standard of care in the management of NLBP.

'Leaving my comfort zone'. A qualitative study of physiotherapists' experiences blending an eHealth psychosocial intervention with face-to-face physiotherapy

BACKGROUND

Many physiotherapists do not feel adequately equipped to address psychosocial risk factors in people with complex pain states. Hence, a biopsychosocial blended intervention (Back2Action) was developed to assist physiotherapists to manage people with persistent spinal pain and coexisting psychosocial risk factors associated with the development or maintenance of persistent pain.

OBJECTIVE

This study aimed to gain insight into the experiences of physiotherapists with this blended psychosocial intervention.

DESIGN

and methods: This was an interpretative qualitative study with a reflexive thematic analysis of semi-structured interviews with physiotherapists (N = 15) who delivered Back2Action. The interview started with the grand-tour question: "What was your experience in using Back2Action?" Physiotherapist were encouraged to provide examples, and follow-up questions were posed to ensure a deeper understanding could be reached.

RESULTS

Four themes were constructed: Physiotherapists became increasingly aware of (1) their own implicit expectations, biases and skills, and underlying treatment paradigms, and (2) the implicit expectations from their patients towards them. This led to (3) creating a deeper and stronger therapeutic alliance with the patient, but also (4) an understanding that implementation of a true biopsychosocial intervention - even if offered in a blended form - requires more practice, confidence and resources.

CONCLUSIONS

Back2Action is considered a valuable treatment to deliver a biopsychosocial intervention in primary care. Considering the high level of knowledge, skills and competency of the participating physiotherapists, the perceived barriers may be more difficult to overcome for more junior physiotherapists.

Cognitive Functional Therapy compared with usual physiotherapy care in people with persistent low back pain: a mixed methods feasibility randomised controlled trial in the United Kingdom National Health Service

OBJECTIVES

To determine the feasibility of completing a definitive randomised controlled trial (RCT), evaluating the clinical and cost-effectiveness of Cognitive Functional Therapy (CFT) in comparison to usual physiotherapy care (UPC), for people with persistent low back pain (LBP).

DESIGN AND SETTING

A two-arm parallel feasibility RCT completed in a United Kingdom (UK) Secondary Care National Health Service (NHS) physiotherapy service.

PARTICIPANTS

Sixty adult participants who reported LBP lasting for more than three months, that was not attributable to a serious (e.g. cancer) or specific (e.g. radiculopathy) underlying cause, were invited to participate. Participants were allocated at random to receive CFT or UPC.

INTERVENTIONS

Cognitive Functional Therapy and Usual Physiotherapy Care for persistent LBP.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of completing a definitive RCT, defined by recruitment of at least 5 participants per month, delivery of CFT per protocol and securing relevant and acceptable outcome measures. Data concerning study processes, resources, management and participant reported outcome measures were collected at baseline, 3, 6 and 12-month follow-up.

RESULTS

Sixty participants (n = 30 CFT and n = 30 UPC) were recruited with 80% (n = 48), 72% (n = 43) and 53% (n = 32) retained at 3, 6 and 12-month follow-up respectively. NHS physiotherapists were trained to competence and delivered CFT with fidelity. CFT was tolerated by participants with no adverse events. Relevant and clinically important outcome data were collected at all time points (0.4%, 3%, 1% and 0.8% of data was missing from the returned outcome measure booklets at baseline and 3, 6 and 12-month follow-up respectively). The Roland-Morris disability questionnaire was considered the most suitable primary outcome measure with a proposed sample size of 540 participants for a definitive cluster RCT.

CONCLUSION

It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future study should incorporate an internal pilot to address aspects of feasibility further, including participant retention strategies.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN12965286 CONTRIBUTION OF THE PAPER.

Process of change for people with knee osteoarthritis undergoing cognitive functional therapy: a replicated single-case experimental design study

PURPOSE

To examine the applicability and process of change of Cognitive Functional Therapy (CFT) in the management of pain and disability in people with knee osteoarthritis who were offered knee replacement surgery and had risk factors for poor response to surgery.

METHODS

Single-case experimental design with a mixed-methods, repeated measures approach was used to investigate the process of change through CFT in four participants. Qualitative interviews investigated beliefs, behaviours and coping responses, and self-reported measures assessed pain, disability, psychological factors, and function at 25 timepoints. Study registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619001491156).

RESULTS

Qualitative data indicate that CFT promoted helpful changes in all participants, with two responses observed. One reflected a clear shift to a biopsychosocial conceptualisation of osteoarthritis, behavioural re-engagement and the view that a knee replacement was no longer necessary. The other response reflected a mixed conceptualisation with dissonant beliefs about osteoarthritis and its management. Psychological and social factors were identified as potential treatment barriers. Overall, quantitative measures supported the qualitative findings.

CONCLUSION

The process of change varies between and within individuals over time. Psychological and social barriers to treatment have implications for future intervention studies for the management of knee osteoarthritis.IMPLICATIONS FOR REHABILITATIONCognitive Functional Therapy is applicable in the management of knee osteoarthritis.Reconceptualisation of osteoarthritis reflected a helpful change.Psychological and social factors emerged as barriers to recovery.

Apigetrin alleviates intervertebral disk degeneration by regulating nucleus pulposus cell autophagy

Background

Intervertebral disk degeneration (IVDD) is a common spine disease, and inflammation is considered to be one of its main pathogenesis. Apigetrin (API) is a natural bioactive flavonoid isolated from various herbal medicines and shows attractive anti-inflammatory and antioxidative properties; whereas, there is no exploration of the therapeutic potential of API on IVDD. Here, we aim to explore the potential role of API on IVDD in vivo and in vitro.

Methods

In vitro, western blotting, real-time quantitative polymerase chain reaction, and immunofluorescence analysis were implemented to explore the bioactivity of API on interleukin-1 beta (IL-1β)-induced inflammatory changes in nucleus pulposus cells (NPCs). In vivo, histological staining and immunohistochemistry were employed to investigate the histological changes of intervertebral disk sections on puncture-induced IVDD rat models.

Results

In vitro, API played a crucial role in anti-inflammation and autophagy enhancement in IL-1β-induced NPCs. API improved inflammation by inhibiting the nuclear factor-kappaB and mitogen-activated protein kinas pathways, whereas it promoted autophagy via the phosphatidylinositol 3-kinase/AKT/mammalian target of the rapamycin pathway. Furthermore, in vivo experiment illustrated that API mitigates the IVDD progression in puncture-induced IVDD model.

Conclusions

API inhibited degenerative phenotypes and promoted autophagy in vivo and in vitro IVDD models. Those suggested that API might be a potential drug or target for IVDD.

Comparison of Pain Characteristics, Strength, and Movement Patterns in Adolescents With Juvenile Fibromyalgia and High Versus Low Fear of Movement

Physical activity avoidance and fear of movement (FOM) is often observed in individuals with chronic musculoskeletal pain, along with difficulties coping with pain. There is little research regarding how FOM may also relate to reduced physical strength and altered movement patterns that may perpetuate a cycle of pain, FOM, and disability. The objective of this observational study was to compare how adolescents with juvenile fibromyalgia (JFM) exhibiting high versus low FOM (Tampa Scale of Kinesiophobia-11) differed on patient-reported measures of pain, fatigue, catastrophizing and pain interference, and performance-based measures of strength, postural control, and biomechanical function. Participants were youth with JFM (N = 135, Meanage = 15.6 years, 88.9% female) enrolled in an ongoing clinical trial who completed self-report questionnaires and standardized tests, including knee and hip strength, the Star Excursion Balance Test, and the Drop Vertical Jump (with 3 dimensional motion capture). Participants were categorized into Low, Medium, and High FOM groups based on Tampa Scale of Kinesiophobia-11 tertile scores. Relative to the Low FOM group, the High FOM group reported significantly greater fatigue, pain interference and catastrophizing, as well as reduced dominant leg knee strength. Additionally, those with high FOM showed altered lower-extremity movement patterns. This preliminary study highlights the importance of combining self-reported measures of symptoms and functioning with physical assessments to gain a more comprehensive view of the impact of FOM in patients with chronic musculoskeletal pain. The results could inform the development of more precise interventions to reduce FOM using a combination of behavioral and exercise-based interventions.

PERSPECTIVE

The results of this study demonstrate the association between FOM, fatigue and pain interference in adolescents with JFM, as well as preliminary evidence for altered movement patterns in that may predispose them to further pain/injury and activity avoidance.

CLINICAL TRIALS

GOV REGISTRATION

NCT03268421.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery

OBJECTIVES

To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway.

DESIGN

A cross-sectional, qualitative study with an interpretive descriptive design.

SETTING

Academic and non-academic hospital setting in Belgium.

PARTICIPANTS

31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed.

RESULTS

Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS.

CONCLUSIONS

This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov (NCT03427294).

Attentional Distractions Do Not Influence Lumbar Spine Local Dynamic Stability during Repetitive Flexion-Extension Movements

The association between low back pain and lumbar spine local dynamic stability (LDS) appears to be modulated by if and how someone catastrophizes about pain, suggesting that the cognitive perceptions of pain may influence an individual's ability to control lumbar spine motion. Previous work also demonstrates that directing cognitive resources and attentional focus can influence movement performance. Therefore, we aimed to examine whether distracting attentional focus would influence lumbar spine LDS during repetitive flexion-extension movements. Sixteen participants performed repetitive spine flexion-extension movements under two baseline conditions (pre- and post-), and while attentional focus was distracted by either an external sensory stimulus or a cognitive-motor dual-task, both targeted at the hands. Lumbar spine LDS was examined over 30 continuous movement repetitions using maximum Lyapunov exponents. In comparison to both Baseline and Post-Baseline trials, the perceived mental workload was significantly elevated during the cognitive-motor dual-task trial but not the external sensory stimulus trial. The only statistically significant effect on LDS occurred in the Post-Baseline trial, where LDS was higher than in the cognitive-motor dual-task. In combination with previous work, these findings suggest that distracting attentional focus during repetitive lumbar spine flexion-extension movements does not have a negative influence on lumbar spine LDS.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): short term effects of a randomised controlled trial in primary care

PURPOSE

To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes.

METHODS

Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants.

RESULTS

The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU (p = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline (p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms.

CONCLUSIONS

The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

An online pain management program for people with hypermobile Ehlers-Danlos Syndrome or hypermobility spectrum disorder: a three-staged development process

PURPOSE

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs.

MATERIALS AND METHODS

A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS).

RESULTS

396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability".

CONCLUSIONS

A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

The influence of low back pain-related attitudes and beliefs on the clinical decision making of physical therapists

BACKGROUND

The LBP-related attitudes and beliefs of clinicians may impact the experience of patients by influencing clinician decision-making and by shaping the attitudes, beliefs, and actions of patients. The purpose of this study was to identify the specific LBP-related attitudes and beliefs of US-based physical therapists and determine if those beliefs correlate with clinical decision-making.

METHODS

An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain and Impairment Relationship Scale for Physiotherapists (PABS-PT). The survey also included 2 patient vignettes that collected information about clinical decision-making.

RESULTS

Complete survey responses were recorded from 420 physical therapists. Eleven of the 27 attitude and beliefs questions were answered in a more biomedically oriented way by at least 20% of respondents. Physical therapist low back pain-related attitudes and beliefs were associated with activity and management strategies for both vignettes in the expected direction. Higher scores on HC-PAIRS and PABS-BM were associated with more restrictive work and activity recommendations, lower-intensity exercise choices, biomechanical rationale for manual therapy and motor control exercises, pathoanatomical-focused education, and use of modalities.

CONCLUSION

Some physical therapists hold biomedically oriented beliefs about the connection between pain and physical activity. Clinician beliefs were associated with activity and work recommendations, and treatment choices. Physical therapists with more biomedically oriented beliefs were more likely to limit physical activity and work, and less likely to incorporate psychologically informed interventions.

A Highly Sensitive and Stretchable Core-Shell Fiber Sensor for Gesture Recognition and Surface Pressure Distribution Monitoring

This work reports a highly-strain flexible fiber sensor with a core-shell structure utilizes a unique swelling diffusion technique to infiltrate carbon nanotubes (CNTs) into the surface layer of Ecoflex fibers. Compared with traditional blended Ecoflex/CNTs fibers, this manufacturing process ensures that the sensor maintains the mechanical properties (923% strain) of the Ecoflex fiber while also improving sensitivity (gauge factor is up to 3716). By adjusting the penetration time during fabrication, the sensor can be customized for different uses. As an application demonstration, the fiber sensor is integrated into the glove to develop a wearable gesture language recognition system with high sensitivity and precision. Additionally, the authors successfully monitor the pressure distribution on the curved surface of a soccer ball by winding the fiber sensor along the ball's surface.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design

INTRODUCTION AND PURPOSE

Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules.

RESULTS

After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration.

DISCUSSION

The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up.

CONCLUSION

CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

Dry Needling with the Use of FRSc Technique in Addition to Standard Rehabilitation Program for Chronic Low Back Pain: A Randomized Controlled Trial Using Both PROMs and Measurement Tools

Purpose

Dry needling (DN) has gained popularity for musculoskeletal conditions, but its commercial use often surpasses scientific evidence. The novel Five Regulatory Systems Concept (FRSc) of DN shows potential therapeutic mechanisms, including chronic low back pain (LBP). However, rigorous clinical assessment with patient-reported outcome measures (PROMs) and objective measures are necessary. This study aimed to evaluate the effect of DN according to pain levels, postural control and selected gait parameters in patients with chronic LBP.

Patients and Methods

This prospective, double-blinded, randomized controlled study involved 30 patients with LBP allocated in the experimental (n=15, rehabilitation+ FRSc DN) or control group (n=15, rehabilitation + sham DN). The Roland-Morris questionnaire (RMQ) and Visual Analog Scale (VAS) were used as PROMs. Moreover, the posturography method for posture and balance control and the treadmill for gait analysis were used as objective tools. Measurements were taken before and immediately after the intervention and during 1- and 3-month follow up.

Results

There was a statistically significantly greater improvement in the RMQ in the experimental group compared to the controls (p=0.923 before and p<0.001 after treatment, as well as p<0.001 after 1 and 3 months). Despite the favorable analgesic effect, a significant advantage of the experimental group over the controls in this respect is worth noting (p=0.001 in favor of DN in all intergroup comparisons concerning results from the subjective assessment of pain (VAS). A statistically insignificant post-treatment improvement in balance and postural stability was noted in both groups, although the effects appeared to be short-term. Surprisingly, again, DN had no advantage over sham interventions. In both groups, all changes in the swing phase were statistically insignificant (p=0.201 for the dominant and p=0.283 for the non-dominant side) for the initial swing phase. In both groups, all changes in the stance phase were statistically insignificant (p=0.480 for the dominant and p=0.410 for the non-dominant side of the body).

Conclusion

DN based on the FRSc appears promising as an effective adjunct to standard rehabilitation for LBP, showing improvements in functional performance and pain reduction.

"I Feel Like I Have Lost Part Of My Identity" - A Qualitative Study Exploring The Impact Of Chronic Ankle Instability

Introduction

Lateral ankle sprain is the most common ankle injury and up to 40% of those who sustain a lateral ankle sprain will develop chronic ankle instability (CAI). The aim of this study was to explore the thoughts and expectations of CAI-patients concerning their condition and expectations of care in an orthopedic setting. .

Study Design

Qualitative study.

Methods

Nine semi-structured one-to-one interviews were conducted with CAI-patients who were referred to an orthopedic setting. Interviews were recorded, transcribed, and analyzed using systematic text condensation with an inductive goal free approach. .

Results

Seven themes emerged. The themes were Injury history and symptoms (Lateral ankle sprain during sport, pain and instability), Information from health professional (conflicting information about management and prognosis), Management (mental and physical challenges), Expectation and hope (explanation of symptoms, prognosis and imaging to provide clarification of condition), Activity and participation (restriction in sport and daily life and feelings of uncertainty), Support (support from family/friends) and Identity (low ability to participate in sport and social life result in loss of identity). .

Conclusion

The impact of CAI exceeds an experience of pain and instability. Patients experienced loss of identity, having to manage uncertainty regarding their diagnosis and prognosis and had hopes of being able to explain their condition. .

Level of Evidence

Not applicable.

Efficacy of cognitive functional therapy in patients with low back pain: A systematic review and meta-analysis

BACKGROUND

Low back pain is a major public health problem worldwide, and there exists evidence that cognitive functional therapy may help improve patients' health condition. However, the utilization of cognitive functional therapy for low back pain is limited, and its clinical efficacy remains unclear.

OBJECTIVES

To determine the efficacy of cognitive functional therapy in the management of disability, pain intensity, and fear-avoidance beliefs in low back pain patients.

DESIGN

Systematic review and meta-analysis.

METHOD

A comprehensive study search of Pubmed, Web of Science, Medline, CINAHL, Embase, PsycINFO, and the Cochrane Library databases was conducted from their inception to August 14th, 2023. Two researchers independently conducted the literature search and data extraction. All statistical analysis was performed using Stata Version 17.0.

RESULTS

A total of eight randomized controlled trials were included. In the short-term, cognitive functional therapy significantly improved disability (7 studies, SMD = -1.05, 95 % CI = -1.74 to -0.35, I2 = 95.37 %, GRADE = very low), pain intensity (7 studies, SMD = -1.02, 95 % CI = -1.89 to -0.15, I2 = 97.21 %, GRADE = very low), and fear-avoidance beliefs (4 studies, SMD = -0.89, 95 % CI = -1.30 to -0.47, I2 = 82.49 %, GRADE = very low). In the medium-term, cognitive functional therapy also significantly improved disability (3 studies, SMD = -0.48, 95 % CI = -0.82 to -0.14, I2 = 77.97 %, GRADE = very low), pain intensity (3 studies, SMD = -0.34, 95 % CI = -0.58 to -0.10, I2 = 55.55 %, GRADE = very low), and fear-avoidance beliefs (2 studies, SMD = -0.62, 95 % CI = -1.19 to -0.04, I2 = 88.24 %, GRADE = very low). In the long-term, cognitive functional therapy significantly improved disability (4 studies, SMD = -0.54, 95 % CI = -0.95 to -0.13, I2 = 85.87 %, GRADE = very low) and fear-avoidance beliefs (3 studies, SMD = -0.76, 95 % CI = -1.17 to -0.34, I2 = 80.34 %, GRADE = very low).

CONCLUSION

Cognitive functional therapy might be effective in reducing disability and fear-avoidance beliefs at any of short-, medium- and long-term follow-ups, and reducing pain at short- and medium-term follow-ups. No definitive conclusions can be drawn about the impact of cognitive functional therapy on low back pain patients due to the very low certainty evidence base. Additional rigorous randomized controlled trials are needed to further confirm these findings.

REGISTRATION NUMBER

CRD42022287123 (PROSPERO).

How Movement Is Assessed Matters. Changes in Forward Bending During Cognitive Functional Therapy Treatment for People With Chronic Low Back Pain

OBJECTIVE: To investigate forward bending range of motion (ROM) and velocity in patients with low back pain who were receiving Cognitive Functional Therapy and determine (1) the amount and timing of change occurring at the trunk and pelvis (global angles), and lumbar spine (intersensor angle), and (2a) differences in changes between participants with and without sensor biofeedback, and (2b) participants with and without baseline movement limitation. DESIGN: Observational study. METHODS: Two hundred sixty-one participants attended Cognitive Functional Therapy treatment and wore sensors at the T12 and S2 spine levels while performing forward bending. Measures included ROM and velocity from both sensors, and the intersensor angle. Regression models estimated changes over time. Time-group interactions tested participants who were subgrouped by treatment and baseline movement. RESULTS: During the 90-day evaluation period, most change occurred in the first 21 days. Changes in ROM observed at T12 (3.3°, 95% CI: 1.0°, 5.5°; P = .001) and S2 (3.3°, 95% CI: 1.2°, 5.4°; P = .002) were similar. Intersensor angle remained similar (0.2°, 95% CI: -2.0°, -1.6°; P = .81). Velocity measured at T12 and S2, and the intersensor angle increased 8.5°/s (95% CI: 6.7°/s, 10.3°/s; P<.0001), 5.3°/s (95% CI: 4.0°/s, 6.5°/s; P<.0001), and 3.4°/s (95% CI: 2.4°/s, 4.5°/s; P<.0001), respectively, for 0 to 21 days. There were minimal differences in participants who received biofeedback. Larger increases occurred in participants with restricted ROM and slower velocity at baseline. CONCLUSION: During 0 to 21 days, we observed changes at the trunk and pelvis (especially in people with reduced ROM), and velocity changes across all measures (especially in people with baseline movement limitations). Biofeedback did not augment the changes. When targeting forward bending in people with low back pain, clinicians should monitor changes in velocity and global ROM. J Orthop Sports Phys Ther 2024;54(3):1-13. Epub 19 December 2023. doi:10.2519/jospt.2023.12023.

Incidence of back pain from initial presentation to 3 years of follow-up in subjects with untreated adolescent idiopathic scoliosis

BACKGROUND

Although back pain may be present in subjects with adolescent idiopathic scoliosis (AIS), its natural history is unknown. Therefore, this study evaluated the incidence of back pain in scoliotic adolescents longitudinally.

METHODS

This retrospective analysis examined prospectively collected pain subscale data of the Scoliosis Research Society questionnaire between the initial presentation and up to 3 years of follow-up. Consecutive subjects with AIS aged 10-18 at baseline managed by observation within the study period were included. Study subjects with at least one time point of follow-up data were considered. Alternatively, a group with physiotherapy-treated was also included for comparison.

RESULTS

We enrolled 428 subjects under observation. The incidence of back pain among study subjects was 14.7%, 18.8%, and 19.0% for the first year, second year, and third year of follow-up, respectively. Most experienced mild pain (1 out of 5 points) throughout the study. Neither incidence nor intensity of pain significantly differed between subjects under observation and received physiotherapy. Additionally, study subjects with a new onset of back pain had poorer function, self-image, and mental health scores than those without pain.

CONCLUSION

We investigated the incidence of back pain longitudinally in subjects suffering from AIS. Further validation of the current results is warranted.

Characterizing clinical progression in patients with musculoskeletal pain by pain severity and central sensitization-related symptoms

Central sensitization-related symptoms (CSS) are associated with the severity and progression of pain. The relationship between the severity of pain/CSS and clinical progresses remains unclear. This multicenter, collaborative, longitudinal study aimed to characterize the clinical outcomes of patients with musculoskeletal pain by classifying subgroups based on the severity of pain/CSS and examining changes in subgroups over time. We measured the pain intensity, CSS, catastrophic thinking, and body perception disturbance in 435 patients with musculoskeletal pain. Reevaluation of patients after one month included 166 patients for pain intensity outcome and 110 for both pain intensity and CSS outcome analysis. We classified the patients into four groups (mild pain/CSS, severe pain/mild CSS, severe pain/CSS, and mild pain/severe CSS groups) and performed multiple comparison analyses to reveal the differences between the CSS severity groups. Additionally, we performed the adjusted residual chi-square to identify the number of patients with pain improvement, group transition, changing pain, and CSS pattern groups at baseline. The most characteristic result was that the mild and severe CSS groups showed worsening pain. Moreover, many of the group transitions were to the same group, with a few transitioning to a group with mild pain/CSS. Our findings suggest that the severity and improvement of CSS influence pain prognosis.

Illness perceptions in people with chronic and disabling non-specific neck pain seeking primary healthcare: a qualitative study

BACKGROUND

Illness perceptions can affect the way people with musculoskeletal pain emotionally and behaviorally cope with their health condition. Understanding patients illness perceptions may help facilitate patient-centered care. The purpose of this study was to explore illness perceptions and the origin of those perceptions in people with chronic disabling non-specific neck pain seeking primary care.

METHODS

A qualitative study using a deductive and inductive analytical approach was conducted in 20 people with persistent (> 3 months) and disabling (i.e., Neck Disability Index ≥ 15) neck pain. Using a semi-structured format, participants were interviewed about their illness perceptions according to Leventhal's Common Sense Model. Purposive sampling and member checking were used to secure validity of study results.

RESULTS

Participants reported multiple symptoms, thoughts and emotions related to their neck pain, which continuously required attention and action. They felt trapped within a complex multifactorial problem. Although some participants had a broader biopsychosocial perspective to understand their symptoms, a biomedical perspective was dominant in the labelling of their condition and their way of coping (e.g., limiting load, building strength and resilience, regaining mobility, keep moving and being meaningful). Their perceptions were strongly influenced by information from clinicians. Several participants indicated that they felt uncertain, because the information they received was contradictory or did not match their own experiences.

CONCLUSION

Most participants reported that understanding their pain was important to them and influenced how they coped with pain. Addressing this 'sense making process' is a prerequisite for providing patient-centered care.

Patterns of Mental Health Service Use in Australian Workers with Low Back Pain: A Retrospective Cohort Study

PURPOSE

To describe the volume, timing and provider of mental health services provided to workers with accepted low back pain (LBP) claims, and to identify determinants of service volume and time to first mental health service.

METHODS

Using claim and service-level workers' compensation data from four Australian states (Queensland, South Australia, Western Australia, Victoria) for LBP claims with at least one mental health service lodged between 1 July 2011 and 30 June 2015. Mental health services occurring 30 days prior to 730 days following claim acceptance were examined. Outcomes were number of mental health services and time (weeks) from claim acceptance to first service, calculated overall, by provider and interaction type, and by independent variables (age group, sex, time loss duration, financial year of lodgement, jurisdiction, socioeconomic status, remoteness). Negative binomial and Cox regression models examined differences between service volume and time to first service by independent variables, respectively.

RESULTS

Of workers with LBP claims who accessed mental health services, psychologist services were most common (used by 91.2% of workers) and 16% of workers saw multiple provider types. Number of services increased with time loss duration, as did time to first service. Victorian workers had the most services, yet accessed them latest.

CONCLUSIONS

Psychologist services were most common, longer duration claims used more mental health services but accessed them later, and there were a number of jurisdictional differences. Results suggest opportunities for workers' compensation authorities to provide, to those who may benefit, greater and earlier access to mental health care.

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.

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.

People With Low Back Pain Exhibit Higher Trunk Muscle Activity and Impaired Postural Control During Static and Dynamic Functional Tasks: A Cross-Sectional Study

The study compared superficial trunk muscle activity and postural control among an active extension subgroup of people with nonspecific chronic low back pain (AE-NSCLBP) with painfree controls during functional tasks. Thirty-two people (17 people with low back pain [LBP] and 15 painfree controls) participated in this study. Muscle activity of 5 trunk muscles and postural control were investigated during both standing tasks (eyes open/closed; single/double-leg balance) and dynamic functional tasks (spinal forward flexion and return, and a sit to stand transfer). Results showed that during single-leg standing, people with AE-NSCLBP exhibit higher muscle activity than painfree controls for 3 trunk muscles, especially with their eyes closed. There were no significant differences in muscle activity between eye conditions during double-leg standing and sit to stand transfer, forward flexion, and return from flexion. The AE-NSCLBP subgroup also demonstrated significantly impaired postural control (lower time to boundary) in 4 of 8 conditions, especially during single-leg standing and with their eyes closed. These findings show people with LBP typically demonstrated greater trunk muscle activity and poorer postural control while maintaining standing posture. This pattern was most evident when the postural challenge was higher, such as single-leg standing or with eyes closed. While this study design cannot infer causality, these findings have implications for LBP rehabilitation, particularly regarding approaches which seek to alter muscle activation among people with LBP.

Exploring the complexity of commonly held attitudes and beliefs of low back pain-a network analysis

Objectives

The current study used a network analysis approach to explore the complexity of attitudes and beliefs held in people with and without low back pain (LBP). The study aimed to (1) quantify the adjusted associations between individual items of the Back Pain Attitudes Questionnaire (Back-PAQ), and (2) identify the items with the strongest connectivity within the network.

Methods

This is a secondary data analysis of a previously published survey using the Back-PAQ (n = 602). A nonparametric Spearman's rank correlation matrix was used as input to the network analysis. We estimated an unregularised graphical Gaussian model (GGM). Edges were added or removed in a stepwise manner until the extended Bayesian information criterion (EBIC) did not improve. We assessed three measures of centrality measures of betweenness, closeness, and strength.

Results

The two pairwise associations with the greatest magnitude of correlation were between Q30-Q31 [0.54 (95% CI 0.44 to 0.60)] and Q15-Q16 [0.52 (95% CI 0.43 to 0.61)]. These two relationships related to the association between items exploring the influence of attentional focus and expectations (Q30-Q31), and feelings and stress (Q15-Q16). The three items with the greatest average centrality values, were Q22, Q25, and Q10. These items reflect beliefs about damaging the back, exercise, and activity avoidance, respectively.

Conclusion

Beliefs about back damage, exercise, and activity avoidance are factors most connected to all other beliefs within the network. These three factors may represent candidate targets that clinicians can focus their counseling efforts on to manage unhelpful attitudes and beliefs in people experiencing LBP.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Attitudes, beliefs, behaviours and perspectives on barriers and enablers of Australian general practitioners towards non-drug interventions: a national survey

BACKGROUND

Many guidelines recommend non-drug interventions (NDIs) for managing common conditions in primary care. However, compared with drug interventions, NDIs are less widely known, promoted and used. We aim to (1) examine general practitioners' (GPs') knowledge, attitudes and practices for NDIs, including their use of the Royal Australian College of General Practitioners (RACGP) Handbook of Non-Drug Interventions (HANDI), and (2) identify factors influencing their use of NDIs and HANDI.

METHODS

We conducted a web-based cross-sectional survey of practicing GP members in Australia during October-November 2022. The survey contained five sections: characteristics of GP; knowledge and use of NDIs; attitudes towards NDIs; barriers and enablers to using HANDI; and suggestions of NDIs and ideas to improve the uptake of NDIs in primary care.

RESULTS

Of the 366 GPs who completed the survey, 242 (66%) were female, and 248 (74%) were ≥45 years old. One in three GPs reported that they regularly ('always') recommend NDIs to their patients when appropriate (34%), whereas one-third of GPs were unaware of HANDI (39%). GPs identified several factors that improve the uptake of HANDI, including 'access and integration of HANDI in clinical practice', 'content and support to use in practice' and 'awareness and training'.

CONCLUSIONS

While many GPs are aware of the effectiveness of NDIs and often endorse their use, obstacles still prevent widespread adoption in primary care. The results of this survey can serve as a foundation for developing implementation strategies to improve the uptake of effective evidence-based NDIs in primary care.

The Role of Illness Perceptions in Dyspnoea-Related Fear in Chronic Obstructive Pulmonary Disease

Dyspnoea is often the most distressing symptom described by people with a chronic respiratory condition. The traditional biomedical model of neuromechanical uncoupling that explains the physiological basis for dyspnoea is well accepted. However, in people with chronic obstructive pulmonary disease (COPD), measures that are linked with neuromechanical uncoupling are poorly related to the restriction in activity during daily life attributed to dyspnoea. This suggests that activity restriction that results from dyspnoea is influenced by factors other than expiratory airflow limitation and dynamic pulmonary hyperinflation, such as the ways people perceive, interpret and respond to this sensation. This review introduces the common-sense model as a framework to understand the way an individual's lay beliefs surrounding sensations can lead to these sensations being perceived as a health threat and how this impacts their emotional and behavioural responses. The aim is to provide insight into the nuances that can shape an individual's personal construct of dyspnoea and offer practical suggestions to challenge unhelpful beliefs and facilitate cognitive re-structuring as a pathway to reduce distress and optimise health behaviours and outcomes.

Improving Rehabilitation Research to Optimize Care and Outcomes for People with Chronic Primary Low Back Pain: Methodological and Reporting Recommendations from a WHO Systematic Review Series

Chronic primary low back pain (CPLBP) is a prevalent and disabling condition that often requires rehabilitation interventions to improve function and alleviate pain. This paper aims to advance future research, including systematic reviews and randomized controlled trials (RCTs), on CPLBP management. We provide methodological and reporting recommendations derived from our conducted systematic reviews, offering practical guidance for conducting robust research on the effectiveness of rehabilitation interventions for CPLBP. Our systematic reviews contributed to the development of a WHO clinical guideline for CPLBP. Based on our experience, we have identified methodological issues and recommendations, which are compiled in a comprehensive table and discussed systematically within established frameworks for reporting and critically appraising RCTs. In conclusion, embracing the complexity of CPLBP involves recognizing its multifactorial nature and diverse contexts and planning for varying treatment responses. By embracing this complexity and emphasizing methodological rigor, research in the field can be improved, potentially leading to better care and outcomes for individuals with CPLBP.

Identification of blood metabolites linked to the risk of intervertebral disc diseases: a comprehensive Mendelian randomization study

BACKGROUND

Intervertebral disc degeneration (IVDD) has affected millions of people worldwide and dramatically affects human beings' quality of life. Observational studies hypothesize that metabolites play key roles as markers and effectors of IVDD, but their causality has not yet been illustrated.

METHODS

We conducted comprehensive Mendelian randomization (MR) to determine the causal relationship between 249 plasma metabolites and IVDD. Inverse-variance weighting was used as the primary estimate, whereas MR-Egger and weighed median were used to detect robustness. A series of sensitivity analyses including Cochran Q test, leave one out, and MR-Egger intercept analysis were also conducted.

RESULTS

In total, we found 13 blood metabolites significantly associated with IVDD, including phospholipids in very large high-density lipoprotein (HDL), free cholesterol to total lipids ratio in very large HDL, average diameter for HDL particles, cholesteryl esters to total lipids ratio in large HDL, free cholesterol to total lipids ratio in medium HDL, creatinine, free cholesterol to total lipids ratio in large HDL, phospholipids to total lipids ratio in very large HDL, cholesterol to total lipids ratio in very large HDL, cholesteryl esters to total lipids ratio in large HDL, phospholipids in large HDL, total lipids in very large HDL, and total lipids in large HDL. No pleiotropy was detected. Heterogeneity existed in several estimates and random-effect inverse-variance weighting was applied.

CONCLUSIONS

Our study highlighted the causal association of blood metabolites with the risk of IVDD. Our results provide new insights into possible treatment protocols controlling the concentration of specific blood metabolites in IVDD patients. Key messages What is already known on this topic Low back pain is the most common symptom for patients with intervertebral disc degeneration (IVDD) and influences the quality of life of large populations. Observational studies have indicated the association between metabolites and IVDD. However, causality has not been determined yet. What this study adds We conducted a comprehensive Mendelian randomization study to reveal the causal effect from 249 blood metabolites on low back pain. A total of 13 metabolites were found to causally affect the risk of IVDD, among which 11 were negatively associated and 2 were positively asscociated. How this study might affect research, practice, or policy These 13 significant metabolites could serve as biomarkers for IVDD and our results provide new insights into possible treatment protocols for IVDD patients.

The potential of a multimodal digital care program in addressing healthcare inequities in musculoskeletal pain management

Digital interventions have emerged as a solution for time and geographical barriers, however, their potential to target other social determinants of health is largely unexplored. In this post-hoc analysis, we report the impact of social deprivation on engagement and clinical outcomes after a completely remote multimodal musculoskeletal (MSK) digital care program managed by a culturally-sensitive clinical team. Patients were stratified in five categories according to their social deprivation index, and cross-referenced with their race/ethnicity, rurality and distance to healthcare facilities. From a total of 12,062 patients from all U.S. states, 8569 completed the program. Higher social deprivation was associated with greater baseline disease burden. We observed that all categories reported pain improvements (ranging from -2.0 95%CI -2.1, -1.9 to -2.1 95%CI -2.3, -1.9, p < 0.001) without intergroup differences in mean changes or responder rates (from 59.9% (420/701) to 66.6% (780/1172), p = 0.067), alongside reduction in analgesic consumption. We observed significant improvements in mental health and productivity across all categories, with productivity and non-work-related functional recovery being greater within the most deprived group. Engagement was high but varied slightly across categories. Together these findings highlight the importance of a patient-centered digital care program as a tool to address health inequities in musculoskeletal pain management. The idea of investigating social deprivation within a digital program provides a foundation for future work in this field to identify areas of improvement.

The smallest worthwhile effect on pain intensity of nonsteroidal anti-inflammatory drugs and exercise therapy for acute and chronic low back pain: a benefit-harm trade-off study

QUESTION

What are the smallest worthwhile effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for people with acute and chronic low back pain (LBP)? What is the smallest worthwhile effect of individualised exercise for people with chronic LBP compared with no intervention?

DESIGN

Benefit-harm trade-off study.

PARTICIPANTS

Participants were recruited by advertisement on social media and included if they were English-speaking adults in Australia who had non-specific LBP.

OUTCOME MEASURE

Pain intensity.

RESULTS

A total of 116 people with acute LBP and 230 people with chronic LBP were recruited. For acute LBP, the smallest worthwhile effect of NSAIDs additional to no intervention was a 30% (IQR 10 to 40%) reduction in pain intensity. For chronic LBP, the smallest worthwhile effect of NSAIDs additional to no intervention was a 27.5% (IQR 10 to 50%) reduction in pain intensity. For chronic LBP, the smallest worthwhile effect of exercise additional to no intervention was a 20% (IQR 10 to 40%) reduction in pain intensity. There were small associations between baseline pain, duration of pain and level of exercise and the smallest worthwhile effect of NSAIDs for acute LBP. There were no other clear associations.

CONCLUSIONS

For people with LBP, the smallest worthwhile effect of exercise and NSAIDs additional to no intervention is approximately a 20 to 30% reduction in pain. These results can inform the interpretation of the effects of NSAIDs and exercise in randomised trials and meta-analyses, incorporating consumers' perspectives. Further research on comparisons between different interventions and on other core LBP outcomes may inform decision-making.

REGISTRATION

OSF osf.io/3erjx/.

What Factors Do Clinicians, Coaches, and Athletes Perceive Are Associated With Recovery From Low Back Pain in Elite Athletes? A Concept Mapping Study

OBJECTIVE: Identify factors that elite sport clinicians, coaches, and athletes perceive are associated with low back pain (LBP) recovery. DESIGN: Concept mapping methodology. METHOD: Participants brainstormed, sorted (thematically), and rated (5-point Likert scales: importance and feasibility) statements in response to the prompt, "What factors are associated with the recovery of an elite athlete from low back pain?" Data cleaning, analysis (multidimensional scaling, hierarchical cluster analysis, and descriptive statistics), and visual representation (cluster map and Go-Zone graph) were conducted following concept mapping guidelines. RESULTS: Participants (brainstorming, n = 56; sorting, n = 34; and rating, n = 33) comprised 75% clinicians, 15% coaches, and 10% athletes and represented 13 countries and 17 sports. Eighty-two unique and relevant statements were brainstormed. Sorting resulted in 6 LBP recovery-related themes: (1) coach and clinician relationships, (2) inter-disciplinary team factors, (3) athlete psychological factors, (4) athlete rehabilitation journey, (5) athlete non-modifiable risk factors, and (6) athlete physical factors. Participants rated important recovery factors as follows: athlete empowerment and psychology, coach-athlete and athlete-clinician relationships, care team communication, return-to-sport planning, and identifying red flags. CONCLUSION: Factors perceived as important to LBP recovery in elite athletes align with the biopsychosocial model of community LBP management. Clinicians should consider that an athlete's psychology, relationships, care team communication, and rehabilitation plan may be as important to their LBP recovery as the formulation of a diagnosis or the medications or exercises prescribed. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub 10 August 2023. doi:10.2519/jospt.2023.11982.

Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain

PURPOSE

Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF.

METHODS

Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes.

RESULTS

Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients.

CONCLUSION

The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.