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Kapos FP, Craig KD, Anderson SR, Bernardes SF, Hirsh AT, Karos K, Keogh E, Reynolds Losin EA, McParland JL, Moore DJ, Ashton-James CE. Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives. THE JOURNAL OF PAIN 2024; 25:104608. [PMID: 38897311 PMCID: PMC11402600 DOI: 10.1016/j.jpain.2024.104608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.
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Affiliation(s)
- Flavia P Kapos
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Orthopaedic Surgery & Duke Clinical Research Institute, Duke University Schoool of Medicine, Durham, North Carolina.
| | - Kenneth D Craig
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven R Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Sónia F Bernardes
- Centre for Social Research and Intervention, Iscte-Lisbon University Institute, Lisbon, Portugal
| | - Adam T Hirsh
- Department of Psychology, Indiana University Indianapolis, Indianapolis, Indiana
| | - Kai Karos
- Experimental Health Psychology, Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Edmund Keogh
- Department of Psychology & Centre for Pain Research, University of Bath, Bath, United Kingdom
| | | | - Joanna L McParland
- Department of Psychology, Glasgow Caledonian University, Glasgow, United Kingdom
| | - David J Moore
- School of Psychology, Liverpool John Moores University, Liverpool, United Kingdom
| | - Claire E Ashton-James
- Pain Management Research Institute, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Bogaert L, Brumagne S, Léonard C, Lauwers A, Peters S. Physiotherapist- and patient-reported barriers to guideline implementation of active physiotherapeutic management of low back pain: A theory-informed qualitative study. Musculoskelet Sci Pract 2024; 73:103129. [PMID: 38943770 DOI: 10.1016/j.msksp.2024.103129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 05/30/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND AND OBJECTIVE Adoption of low back pain (LBP) guidelines in physiotherapeutic management is a well-documented problem. Thereby, an in-depth understanding of the barriers to implement an active approach for both patients and physiotherapists is needed. DESIGN Semi-structured interviews were conducted with physiotherapists and patients with non-specific LBP. Interviews, guided by the Theoretical Domains Framework (TDF), were analyzed using the Qualitative Analysis Guide of Leuven. RESULTS A total of 20 participants were interviewed, including ten physiotherapists and ten patients. Our findings reveal that patients and physiotherapists face each 23 barriers spanning 14 TDF domains. The TDF domain "social influences" revealed the most barriers, followed by "beliefs about consequences" and "environmental context" for patients and physiotherapists, respectively. Five barriers did overlap between both groups (lack of guideline awareness, incorrect exercise performance, interdisciplinary communication gaps, time constraints and challenges in patient compliance). CONCLUSIONS Barriers to LBP guideline recommended physiotherapeutic practices span all 14 TDF domains. Consequently, future implementation interventions need to address multiple TDF domains for effective LBP guideline implementation.
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Affiliation(s)
- Liedewij Bogaert
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium; REVAL Rehabilitation Research, Hasselt University, Diepenbeek, Belgium.
| | - Simon Brumagne
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | | | - Amber Lauwers
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Sanne Peters
- School of Health Sciences, University of Melbourne, Australia
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Klem NR, O'Sullivan P, Smith A, Schütze R. A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial. QUALITATIVE HEALTH RESEARCH 2024:10497323241268777. [PMID: 39250737 DOI: 10.1177/10497323241268777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients' perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of "The Journey to Self-Management." Within this overarching narrative, four distinct narratives were identified, beginning with "Left High and Dry," capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included "Plain, Smooth Sailing," describing a journey of relative ease and lack of obstacles; "Learning the Ropes and Gaining Sea Legs," capturing an iterative process of learning and negotiating setbacks; and "Sailing Through Headwinds," describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.
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Affiliation(s)
- Nardia-Rose Klem
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Peter O'Sullivan
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Anne Smith
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Robert Schütze
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Royal Perth Hospital Multidisciplinary Pain Management Centre, Perth, WA, Australia
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Watson ED, Marshall PW, Morrison NMV, Moloney N, O'Halloran P, Rabey M, Niazi IK, Stevens K, Kingsley M. Breaking the cycle of reoccurring low back pain with integrated motivational interviewing and cognitive behavioural therapy to facilitate education and exercise advice: a superiority randomised controlled trial study protocol. BMC Public Health 2024; 24:2415. [PMID: 39237978 PMCID: PMC11375947 DOI: 10.1186/s12889-024-19930-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 08/29/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Non-specific low back pain is a common and costly global issue. Many people with low back pain live for years with ongoing symptom recurrence and disability, making it crucial to find effective prevention strategies. Motivational interviewing (MI) is an evidence-based patient-centred counselling style that helps motivate individuals to change their behaviours. In combination, MI and cognitive-behavioural therapy (MI-CBT) has the potential to yield long term improvements in pain and disability and reduce incidence of recurrence. METHOD This is a two-arm superiority randomised controlled trial comparing MI-CBT and Education (n = 83) with Education only (n = 83). Participants that have recovered from a recent episode of non-specific low back pain (7th consecutive day with pain ≤ 2 on a 0-10 numeric pain rating scale) will be eligible for inclusion into the study. Both groups will receive five 30-min sessions over a 10-week period as well as the Navigating Pain booklet, homework book and a standardised exercise programme. In the intervention group, MI-CBT techniques will be used to provide individualised support, identify beliefs, and increase engagement with the resources provided. Outcomes measures include pain (current and in the last 7 days) as rated on the numeric pain rating scale. This will be used to determine recurrence (number of participants who report back pain ≥ 3 out of 10 on the numeric pain rating scale). Furthermore, self-reported (1) pain intensity; (2) pain catastrophizing; (3) fear-avoidance beliefs; (4) pain self-efficacy; (5) depression and anxiety; (6) disability will be measured. All outcomes will be measured at baseline, and again at 3-, 6-, and 12-months post allocation. DISCUSSION The effective delivery of self-management strategies to prevent recurrence of low back pain is an important aspect that requires urgent attention. This study will provide new information on the effectiveness of using an MI-CBT approach to facilitate self-management through education and exercise to improve low back pain outcomes. Evidence emerging from this trial has the potential to inform clinical practice and healthcare management of non-specific low back pain. TRIAL REGISTRATION Prospectively registered with Australian New Zealand Clinical Trials Registry: ACTRN12623000746639 (10/07/2023).
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Affiliation(s)
- Estelle D Watson
- Department of Exercise Science, Faculty of Science, University of Auckland, Auckland, New Zealand.
| | - Paul W Marshall
- Department of Exercise Science, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Natalie M V Morrison
- Translational Health Research Institute Western Sydney University, Sydney, Australia
| | - Niamh Moloney
- Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Paul O'Halloran
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Martin Rabey
- Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Imran Khan Niazi
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Kirk Stevens
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Michael Kingsley
- Department of Exercise Science, Faculty of Science, University of Auckland, Auckland, New Zealand
- Holsworth Research Initiative, La Trobe University, Melbourne, Australia
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Berardo A, Bonaldi L, Stecco C, Fontanella CG. Biomechanical properties of the human superficial fascia: Site-specific variability and anisotropy of abdominal and thoracic regions. J Mech Behav Biomed Mater 2024; 157:106637. [PMID: 38914036 DOI: 10.1016/j.jmbbm.2024.106637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/30/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
Superficial fascia is a fibrofatty tissue found throughout the body. Initially described in relation to hernias, it has only recently received attention from the scientific community due to new evidence on its role in force transmission and structural integrity of the body. Considering initial difficulties in its anatomical identification, to date, a characterization of the superficial fascia through mechanical tests is still lacking. The mechanical properties of human superficial fasciae of abdominal and thoracic districts (back) of different subjects (n = 4) were then investigated, focusing on anisotropy and viscoelasticity. Experimental tests were performed on samples taken in two perpendicular directions according to body planes (cranio-caudal and latero-medial axes). Data collected from two different uniaxial tensile protocols, failure (i.e., ultimate tensile strength and strain at break, Young's modulus and toughness) and stress-relaxation (i.e., residual stress), were processed and then grouped for statistical analysis. Failure tests confirmed tissue anisotropy, revealing the stiffer nature of the latero-medial direction compared to the cranio-caudal one, for both the districts (with a ratio of the respective Young's moduli close to 2). Furthermore, the thoracic region exhibited significantly greater strength and resultant Young's modulus compared to the abdomen (with greater results along the latero-medial direction, such as 6.13 ± 3.11 MPa versus 0.85 ± 0.39 MPa and 24.87 ± 15.23 MPa versus 3.19 ± 1.62 MPa, respectively). On the contrary, both regions displayed similar strain at break (varying between 38 and 47%), with no clear dependence from the loading directions. Stress-relaxation tests highlighted the viscous behavior of the superficial fascia, with no significant differences in the stress decay between directions and districts (35-38% of residual stress after 300 s). All these collected results represent the starting point for a more in-depth knowledge of the mechanical characterization of the superficial fascia, which can have direct implications in the design, implementation, and effectiveness of site-specific treatments.
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Affiliation(s)
- Alice Berardo
- Department of Civil, Environmental and Architectural Engineering, University of Padova, 35131, Padova, Italy; Centre for Mechanics of Biological Materials, University of Padova, 35131, Padova, Italy
| | - Lorenza Bonaldi
- Department of Civil, Environmental and Architectural Engineering, University of Padova, 35131, Padova, Italy; Centre for Mechanics of Biological Materials, University of Padova, 35131, Padova, Italy.
| | - Carla Stecco
- Centre for Mechanics of Biological Materials, University of Padova, 35131, Padova, Italy; Department of Neuroscience, Institute of Human Anatomy, University of Padova, 35121, Padova, Italy
| | - Chiara Giulia Fontanella
- Centre for Mechanics of Biological Materials, University of Padova, 35131, Padova, Italy; Department of Industrial Engineering, University of Padova, 35131, Padova, Italy
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Reneman MF, Coenen P, Kuijer PPFM, van Dieën JH, Holtermann A, Igwesi-Chidobe CN, Parker R, Reezigt R, Stochkendahl MJ, Hoegh M. Tensions of Low-Back Pain and Lifting; Bridging Clinical Low-Back Pain and Occupational Lifting Guidelines. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:473-480. [PMID: 38842652 DOI: 10.1007/s10926-024-10210-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Affiliation(s)
- Michiel F Reneman
- Department of Rehabilitation / Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Pieter Coenen
- Department of Public and Occupational Health, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Societal Participation and Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Musculoskeletal Health, Amsterdam Movement Sciences Research Institute, Amsterdam, The Netherlands
| | - P Paul F M Kuijer
- Department of Public and Occupational Health, Netherlands Center for Occupational Diseases, People and Work Outpatient Clinic, Amsterdam Public Health Research Institute, Amsterdam Movement Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jaap H van Dieën
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andreas Holtermann
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Chinonso Nwamaka Igwesi-Chidobe
- School of Allied Health Professions and Midwifery, Faculty of Health Studies, University of Bradford, Bradford, UK
- Global Population Health (GPH) Research Group, University of Nigeria, Nsukka, Nigeria
| | - Romy Parker
- Pain Unit, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Roland Reezigt
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences-Program Musculoskeletal Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Physiotherapy, Academy of Health, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Mette J Stochkendahl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Morten Hoegh
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Kowalski KL, Mistry J, Beilin A, Goodman M, Lukacs MJ, Rushton A. Physical functioning in the lumbar spinal surgery population: A systematic review and narrative synthesis of outcome measures and measurement properties of the physical measures. PLoS One 2024; 19:e0307004. [PMID: 39208263 PMCID: PMC11361614 DOI: 10.1371/journal.pone.0307004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/26/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND International agreement supports physical functioning as a key domain to measure interventions effectiveness for low back pain. Patient reported outcome measures (PROMs) are commonly used in the lumbar spinal surgery population but physical functioning is multidimensional and necessitates evaluation also with physical measures. OBJECTIVE 1) To identify outcome measures (PROMs and physical) used to evaluate physical functioning in the lumbar spinal surgery population. 2) To assess measurement properties and describe the feasibility and interpretability of physical measures of physical functioning in this population. STUDY DESIGN Two-staged systematic review and narrative synthesis. METHODS This systematic review was conducted according to a registered and published protocol. Two stages of searching were conducted in MEDLINE, EMBASE, Health & Psychosocial Instruments, CINAHL, Web of Science, PEDro and ProQuest Dissertations & Theses. Stage one included studies to identify physical functioning outcome measures (PROMs and physical) in the lumbar spinal surgery population. Stage two (inception to 10 July 2023) included studies assessing measurement properties of stage one physical measures. Two independent reviewers determined study eligibility, extracted data and assessed risk of bias (RoB) according to COSMIN guidelines. Measurement properties were rated according to COSMIN criteria. Level of evidence was determined using a modified GRADE approach. RESULTS Stage one included 1,101 reports using PROMs (n = 70 established in literature, n = 67 developed by study authors) and physical measures (n = 134). Stage two included 43 articles assessing measurement properties of 34 physical measures. Moderate-level evidence supported sufficient responsiveness of 1-minute stair climb and 50-foot walk tests, insufficient responsiveness of 5-minute walk and sufficient reliability of distance walked during the 6-minute walk. Very low/low-level evidence limits further understanding. CONCLUSIONS Many physical measures of physical functioning are used in lumbar spinal surgery populations. Few have investigations of measurement properties. Strongest evidence supports responsiveness of 1-minute stair climb and 50-foot walk tests and reliability of distance walked during the 6-minute walk. Further recommendations cannot be made because of very low/low-level evidence. Results highlight promise for a range of measures, but prospective, low RoB studies are required.
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Affiliation(s)
- Katie L. Kowalski
- School of Physical Therapy, Western University, London, Ontario, Canada
- Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Jai Mistry
- School of Physical Therapy, Western University, London, Ontario, Canada
- Physiotherapy, St George’s Hospital, London, United Kingdom
| | - Anthony Beilin
- School of Physical Therapy, Western University, London, Ontario, Canada
| | - Maren Goodman
- Western Libraries, Western University, London, Ontario, Canada
| | - Michael J. Lukacs
- School of Physical Therapy, Western University, London, Ontario, Canada
- Physiotherapy Department, London Health Sciences Centre, London, Ontario, Canada
| | - Alison Rushton
- School of Physical Therapy, Western University, London, Ontario, Canada
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Venkataraman A, Hong IZ, Ho LC, Teo TL, Ang SHC. Public Perceptions on the Use of the Physical Activity Readiness Questionnaire. Healthcare (Basel) 2024; 12:1686. [PMID: 39273711 PMCID: PMC11395539 DOI: 10.3390/healthcare12171686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/06/2024] [Accepted: 08/22/2024] [Indexed: 09/15/2024] Open
Abstract
Self-administered pre-participation screening for physical activity (PA) requires an instrument that should be easily used and identify individuals at high risk. The Physical Activity Readiness Questionnaire (PAR-Q+) has been used for many years. Its ease of use and ability to identify those not fit to undergo PA has not been assessed. This study was to determine the rates of the PAR-Q+ in identifying adults who may not be fit for moderate or intense PA and obtain feedback on the use of this tool. A randomized, cross-sectional study involving a wide spectrum of members of the public was carried out. Participants were asked to provide their bio-characteristics, complete the PARQ+, and provide feedback on the questionnaire. With 1019 participants, about 33.1% of the participants using the PARQ+ would have required further medical evaluation. Except for those patients with respiratory illness, there was no difference in levels of PA in those who answered yes or no to the seven PARQ+ questions. Only 4 of the 7 main PAR-Q+ questions were perceived by the public as easily understood. Difficulties were encountered with 21 of the 45 follow-up questions, especially amongst those with co-morbidities. The wordiness of the questions and the large number of technical terms were also sources of concern. Suggestions were provided by participants on areas where improvements may be made to the wording of the questions. The study suggests that the PAR-Q+ probably over-identified those who require further medical evaluation. In addition, the wordiness of the questions and frequent use of medical jargon made the PARQ+ challenging to understand and use. The suggestions provide opportunities to review areas for possible improvements.
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Affiliation(s)
- Anantharaman Venkataraman
- Department of Emergency Medicine, Singapore General Hospital, Emergency Medicine Academic Clinical Program, Duke-NUS Academic Medical Centre, Outram Road, Singapore 169608, Singapore
| | - Ian Zhirui Hong
- Department of Emergency Medicine, Singapore General Hospital, Emergency Medicine Academic Clinical Program, Duke-NUS Academic Medical Centre, Outram Road, Singapore 169608, Singapore
| | - Lisa Cuiying Ho
- Department of Orthopaedic Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886, Singapore
| | - Tess Lin Teo
- Department of Emergency Medicine, Singapore General Hospital, Emergency Medicine Academic Clinical Program, Duke-NUS Academic Medical Centre, Outram Road, Singapore 169608, Singapore
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Feldman R, Pincus T, Ben Ami N. 'A challenge to my professional identity'- resisting the shift from over-management to self-management for back pain within an implementation trial: a qualitative study. Physiotherapy 2024; 125:101424. [PMID: 39357271 DOI: 10.1016/j.physio.2024.101424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 08/10/2024] [Accepted: 08/13/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVE The Enhanced Transtheoretical Model Intervention (ETMI) is based on behavioral models and focuses on guiding Chronic Low Back Pain (CLBP) patients to self-manage symptoms and engage in recreational physical activity. While there is promising evidence that ETMI benefits patients, it is unclear how challenging it might be to implement widely. This investigation focused on the perceptions of physiotherapists trained to deliver ETMI for CLBP. DESIGN A Qualitative study comprised of semi-structured interviews (July to November 2023). Interviews were audio-recorded, transcribed, coded, and analyzed thematically by two independent researchers. SETTING Data were obtained as part of a large implementation study evaluating the uptake and impact of ETMI amongst physiotherapists in a large public healthcare setting. PARTICIPANTS 22 physiotherapists trained to deliver the ETMI approach and chose to use it with at least one patient. RESULTS While physiotherapists acknowledged the evidence base behind ETMI and the clarity of the approach, they struggled to adapt it to routine delivery. Exploration of the reasons for this identified an overarching meta-theme, 'A challenge to my professional identity', and three main themes consisting of 1) interventions such as ETMI contradicted my training. 2) I am ambivalent/ do not accept evidence that contradicts my habitual practice, and 3) I am under-skilled in psychological and communication skills. CONCLUSION This study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. The shift from over-management by experts seeking cures to supporting self-management was not palatable to physiotherapists. The challenge of embracing a new professional identity must be addressed to enable a successful implementation of the approach. CONTRIBUTION OF THE PAPER.
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Affiliation(s)
- Ron Feldman
- Department of Physical Therapy, Ariel University, Ariel, Israel; Department of Physical Therapy, Maccabi Healthcare Services, Tel-Aviv, Israel.
| | - Tamar Pincus
- School of Psychology, University of Southampton, Southampton, United Kingdom.
| | - Noa Ben Ami
- Department of Physical Therapy, Ariel University, Ariel, Israel.
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Gottlieb M, Bernard K. Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023. Am J Emerg Med 2024; 82:125-129. [PMID: 38905718 DOI: 10.1016/j.ajem.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION Low back pain is a common reason for presentation to the Emergency Department (ED). However, there are limited large-scale, recent data on the epidemiology, disposition, and medication administration for this condition. The objective of this was to assess the incidence, admission rates, medication administrations, and discharge prescriptions among ED visits for low back pain in the United States. METHODS This was a cross-sectional study of ED presentations for low back pain from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits for adults with low back pain identified by ICD-10 codes were included. Outcomes included admission rates, distribution of opioid, benzodiazepine, (non-benzodiazepine) muscle relaxant, acetaminophen, NSAID, and corticosteroid medications administered in the ED, and distribution of opioid, benzodiazepine, muscle relaxant, and corticosteroid medications given upon discharge. Subgroup analyses were performed by specific medication. RESULTS Of 207,154,419 ED encounters, 12,241,240 (5.9%) were due to back pain with 1,957,299 of these (16.0%) admitted. The admission rate increased over time from 12.8% to 17.1%. The most common medication given in the ED was opioids (40.7%), followed by acetaminophen (37.8%), NSAIDs (22.6%), muscle relaxants (18.4%) benzodiazepines (12.8%), and corticosteroids (5.5%). The most common medications prescribed upon discharge were muscle relaxants (32.1%), followed by opioids (23.2%), corticosteroids (12.2%), and benzodiazepines (3.0%). CONCLUSION Low back pain represents a common reason for presentation to the ED, and admissions have been increasing over time. Opioids remain the most common ED medication, whereas muscle relaxants have arisen as the most common discharge prescription. These findings can help inform health policy decisions, resource allocation, and evidence-based interventions for medication administration.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Kyle Bernard
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Gevers-Montoro C, Romero-Santiago B, Medina-García I, Larranaga-Arzamendi B, Álvarez-Gálovich L, Ortega-De Mues A, Piché M. Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial. THE JOURNAL OF PAIN 2024; 25:104500. [PMID: 38369221 DOI: 10.1016/j.jpain.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 02/04/2024] [Accepted: 02/11/2024] [Indexed: 02/20/2024]
Abstract
Chronic primary low back pain (CPLBP) refers to low back pain that persists over 3 months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective in relieving CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n = 49) or a control intervention (n = 49), 12 times over 4 weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in 4 body regions, pain catastrophizing, Central Sensitization Inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (P < .001) and higher scores for all questionnaires (P < .001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% confidence interval, -11.0 to -12.5], P = .01), but not disability (P = .5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (P < .05). Pain catastrophizing was reduced after SMT compared with the control intervention (P < .05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE: This randomized controlled trial found that 12 sessions of SMT yield greater relief of CPLBP than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.
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Affiliation(s)
- Carlos Gevers-Montoro
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois- Rivières, Quebec, Canada; CogNAC Research Group, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada; Madrid College of Chiropractic, RCU María Cristina, San Lorenzo de El Escorial, Madrid, Spain
| | - Blanca Romero-Santiago
- Madrid College of Chiropractic, RCU María Cristina, San Lorenzo de El Escorial, Madrid, Spain
| | - Isabel Medina-García
- Madrid College of Chiropractic, RCU María Cristina, San Lorenzo de El Escorial, Madrid, Spain
| | | | - Luis Álvarez-Gálovich
- Instituto Avanzado de Columna, Fundación Jiménez Díaz Hospital, Madrid, Madrid, Spain; Fujitega Research Foundation, Madrid, Madrid, Spain
| | | | - Mathieu Piché
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois- Rivières, Quebec, Canada; CogNAC Research Group, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
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12
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Lemmers GPG, Melis RJF, Hak R, de Snoo EK, Pagen S, Westert GP, Staal JB, van der Wees PJ. The association of physical activity and sedentary behaviour with low back pain disability trajectories: A prospective cohort study. Musculoskelet Sci Pract 2024; 72:102954. [PMID: 38691981 DOI: 10.1016/j.msksp.2024.102954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/22/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of risk factors might contribute to a better understanding of the course of LBP. OBJECTIVES To investigate the association of habitual physical activity (PA) and sedentary behaviour (SB), measured at baseline, with disability trajectories in adults with LBP. METHODS A prospective cohort study where habitual PA levels were measured using the Short QUestionnaire to ASsess Health enhancing physical activity (SQUASH), SB was calculated as average sedentary hours per day, and LBP disability using the Oswestry Disability Index (ODI). Participants completed the questionnaires at one and a half, three, six, and twelve months. Linear mixed models were estimated to describe the association of habitual PA levels SB measured at baseline with disability trajectories. Other predictors were gender, education level, age, pain, number of previous episodes of LBP, and duration of LBP. RESULTS Habitual SB measured at baseline in adults (n = 347) with LBP were not associated with disability trajectories. For PA, participants with one metabolic equivalent of task (MET) hour per day above average recovered 0.04 [95% CI 0.004 to 0.076] points on the ODI per month faster than participants with an average amount of MET hours per day. CONCLUSIONS Habitual SB was not associated with LBP disability trajectories over a one-year follow-up. High levels of habitual PA at baseline were associated with improved recovery in LBP disability trajectory, but the finding is not clinically relevant.
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Affiliation(s)
- Gijs Petrus Gerardus Lemmers
- Radboud University Medical Center, IQ Health, Kapittelweg 54, 6525 EP, Nijmegen, the Netherlands; Dutch Healthcare Authority, Newtonlaan 1-41, 3584 BX, Utrecht, the Netherlands.
| | - René Johannes Fransiscus Melis
- Radboud University Medical Center, Department of Geriatric Medicine, Reinier Postlaan 4, 6525 EX, Nijmegen, the Netherlands.
| | - Robin Hak
- Fysius Back Experts, Bedrijvenweg 7, 7442 CX, Nijverdal, the Netherlands.
| | | | - Sophie Pagen
- TheFysioclub, Vicaris van der Asdonckstraat 55, 5421 VB, Gemert, the Netherlands.
| | - Gerard Pieter Westert
- Radboud University Medical Center, IQ Health, Kapittelweg 54, 6525 EP, Nijmegen, the Netherlands.
| | - Jacobus Bart Staal
- Radboud University Medical Center, IQ Health, Kapittelweg 54, 6525 EP, Nijmegen, the Netherlands; Musculoskeletal Rehabilitation Research Group, HAN University of Applied Sciences, Kapittelweg 33, 6525 EN, Nijmegen, the Netherlands.
| | - Philip Jan van der Wees
- Radboud University Medical Center, IQ Health, Kapittelweg 54, 6525 EP, Nijmegen, the Netherlands.
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13
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Rauseo C, Cheng MS. Unlocking Patient Voices: Advancing Physical Therapist Practice With Discrete Choice Experiments. Phys Ther 2024; 104:pzae063. [PMID: 38624225 DOI: 10.1093/ptj/pzae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/07/2024] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
As health care moves away from volume-based to value-based delivery, the role of the patient in determining value in health care is now paramount. Thus, health care should be aligned with what matters most to patients. Ascertaining patient preferences is therefore critical if we are to provide patients with care that is meaningful to them. However, preferences are difficult to measure and traditional methods of preference measurement in physical therapy face challenges when attempting to measure such. This perspective makes a case for greater use of the discrete choice experiment (DCE) in physical therapy as a research method to measure patient preferences. The DCE is a research method used to elicit preferences for services or goods. This article addresses the importance of eliciting patient preferences as part of person-centered care in the value-based space, the challenges faced in preference measurement in physical therapy, and how the DCE can alleviate some of those challenges. It also provides examples of the DCE in health care and suggests ways in which it can be effectively used in physical therapist practice to improve the delivery of meaningful rehabilitation services to patients. Implementing greater use of the DCE in physical therapy can improve person-centered physical therapist service delivery and inform policy development that creates cost-effective care which is meaningful to patients. It can further help to highlight the value of physical therapy to population health, and to policy makers as health care moves toward more value-based models.
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Affiliation(s)
- Carla Rauseo
- Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Mingshun Samuel Cheng
- Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida, USA
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14
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Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Sayed D, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Maislin G, Heemels JP, Eldabe S. Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction. Neuromodulation 2024; 27:930-943. [PMID: 38483366 DOI: 10.1016/j.neurom.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Adults with refractory, mechanical chronic low back pain associated with impaired neuromuscular control of the lumbar multifidus muscle have few treatment options that provide long-term clinical benefit. This study hypothesized that restorative neurostimulation, a rehabilitative treatment that activates the lumbar multifidus muscles to overcome underlying dysfunction, is safe and provides relevant and durable clinical benefit to patients with this specific etiology. MATERIALS AND METHODS In this prospective five-year longitudinal follow-up of the ReActiv8-B pivotal trial, participants (N = 204) had activity-limiting, moderate-to-severe, refractory, mechanical chronic low back pain, a positive prone instability test result indicating impaired multifidus muscle control, and no indications for spine surgery. Low back pain intensity (10-cm visual analog scale [VAS]), disability (Oswestry Disability Index), and quality of life (EuroQol's "EQ-5D-5L" index) were compared with baseline and following the intent-to-treat principle, with a supporting mixed-effects model for repeated measures that accounted for missing data. RESULTS At five years (n = 126), low back pain VAS had improved from 7.3 to 2.4 cm (-4.9; 95% CI, -5.3 to -4.5 cm; p < 0.0001), and 71.8% of participants had a reduction of ≥50%. The Oswestry Disability Index improved from 39.1 to 16.5 (-22.7; 95% CI, -25.4 to -20.8; p < 0.0001), and 61.1% of participants had reduction of ≥20 points. The EQ-5D-5L index improved from 0.585 to 0.807 (0.231; 95% CI, 0.195-0.267; p < 0.0001). Although the mixed-effects model attenuated completed-case results, conclusions and statistical significance were maintained. Of 52 subjects who were on opioids at baseline and had a five-year visit, 46% discontinued, and 23% decreased intake. The safety profile compared favorably with neurostimulator treatments for other types of back pain. No lead migrations were observed. CONCLUSION Over a five-year period, restorative neurostimulation provided clinically substantial and durable benefits with a favorable safety profile in patients with refractory chronic low back pain associated with multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02577354; registration date: October 15, 2016; principal investigator: Christopher Gilligan, MD, Brigham and Women's Hospital, Boston, MA, USA. The study was conducted in Australia (Broadmeadow, New South Wales; Noosa Heads, Queensland; Welland, South Australia; Clayton, Victoria), Belgium (Sint-Niklaas; Wilrijk), The Netherlands (Rotterdam), UK (Leeds, London, Middlesbrough), and USA (La Jolla, CA; Santa Monica, CA; Aurora, CO; Carmel, IN; Indianapolis, IN; Kansas City, KS; Boston, MA; Royal Oak, MI; Durham, NC; Winston-Salem, NC; Cleveland, OH; Providence, RI; Spartanburg, SC; Spokane, WA; Charleston, WV).
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Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Vivek Mehta
- Barts Neuromodulation Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, USA
| | - Edgar Ross
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Alexios Carayannopoulos
- Departments of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, USA
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, USA
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, USA
| | - James Rathmell
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Greg Maislin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
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15
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Mikkonen J, Luomajoki H, Airaksinen O, Goubert L, Pratscher S, Leinonen V. Identical movement control exercises with and without synchronized breathing for chronic non-specific low back pain:A randomized pilot trial. J Back Musculoskelet Rehabil 2024:BMR230413. [PMID: 39031339 DOI: 10.3233/bmr-230413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
BACKGROUND Exercise is a first-line treatment for chronic non-specific low back pain (CNSLBP). Exercise combined with specific breathing techniques have the potential to improve multifactorial outcomes. No previous studies, however, have compared outcomes between identical exercises with or without a specific breathing protocol in a uniform clinical study setting. OBJECTIVES 1) To investigate the feasibility of combining synchronized breathing with movement control exercises and evaluate eligibility criteria, randomization procedures, and dropout rates. 2) To study the preliminary efficacy of the interventions on multifactorial outcome measures. METHODS Thirty subjects with CNSLBP were randomized into two groups. Both groups had four contact clinic visits where they received personalized home movement control exercises to practice over two months. The experimental group included a movement control exercise intervention combined with synchronized breathing techniques. Trial registration number: NCT05268822. RESULTS Feasibility was demonstrated by meeting the recruitment goal of 30 subjects within the pre-specified timeframe with enrolment rate of 24.8% (30/121). Synchronized breathing techniques were successfully adhered by participants. Home exercise adherence was nearly identical between the groups without any adverse events. Preliminary efficacy findings on pain intensity, disability, and self-efficacy in the experimental group exceeded the minimal clinically important difference. No such findings were observed in any outcome measures within the control group. Overall, multifactorial differences were consistent because nine out of eleven outcome measures showed greater improvements for the experimental group. CONCLUSION The synchronized breathing with movement control exercises protocol was feasible and may be more beneficial for improving multifactorial outcomes compared to identical exercises alone. Results suggested progression to a full-scale trial.
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Affiliation(s)
- Jani Mikkonen
- Private Practice, Helsinki, Finland
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hannu Luomajoki
- ZHAW School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Olavi Airaksinen
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Liesbet Goubert
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Steven Pratscher
- Department of Community Dentistry and Behavioral Sciences, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
| | - Ville Leinonen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
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16
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Tanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Musculoskeletal Care 2024; 22:e1898. [PMID: 38862275 DOI: 10.1002/msc.1898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process. AIM Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management. DESIGN Scoping review. METHOD This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories. RESULTS After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors. CONCLUSIONS The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.
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Affiliation(s)
- Luke Tanner
- Clinical Physiotherapist, Auckland, New Zealand
| | - Nicola L Saywell
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
| | - Thomas Adams
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Imran Khan Niazi
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Julia Hill
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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17
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O'Hagan ET, Traeger AC, Schabrun SM, O'Neill S, Wand BM, Cashin AG, Williams CM, Harris IA, McAuley JH. It's OK to Move! Effect of a Brief Video on Community Confidence in Activity Despite Back Pain: A Randomized Trial. J Orthop Sports Phys Ther 2024; 54:400-407. [PMID: 38635937 DOI: 10.2519/jospt.2024.12412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVE: To estimate the difference in confidence to become active despite low back pain in people who were exposed to one of 2 video interventions delivered on social media, compared to no intervention. DESIGN: A proof-of-concept, 3-group randomized controlled trial, in a 1:1:1 ratio. METHODS: Participants aged 18 years and over, with and without low back pain, were recruited via the social media channel Facebook, to view either a humorous video, a neutral video, or to no intervention. The videos were delivered online, explained evidence-based management for low back pain, and were designed to "go viral." The primary outcome was confidence in becoming active despite pain, measured using the Pain Self Efficacy Questionnaire (Item 10) (ranges from 0 [not at all confident] to 6 [completely confident]) immediately after watching the video. We aimed to capture the real-time impact and immediate reactions that contributed to the content's reach. RESULTS: Among 1933 randomized participants (mean [standard deviation] age: 58.9 [14.0] years, 1285 [75%] women), 1232 [70%] had low back pain and 88.8% completed the primary outcome. One thousand two hundred sixty-four participants were randomized to receive a video intervention, and 633 participants did not receive a video. On a 6-point scale, individuals exposed to either video (n = 1088) showed a mean confidence level 0.3 points higher (95% confidence interval: 0.1, 0.6) compared with no video (n = 630). CONCLUSION: Participants who viewed a brief video intervention reported a very small difference in confidence to become active despite low back pain, compared with no intervention. The difference may lack clinical relevance. J Orthop Sports Phys Ther 2024;54(6):1-8. Epub 18 April 2024. doi:10.2519/jospt.2024.12412.
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Affiliation(s)
- Edel T O'Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead, Australia
- Musculoskeletal Clinical Academic Group, Maridulu Budyari Gumal (SPHERE), Sydney, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Siobhan M Schabrun
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, Australia
- Musculoskeletal Clinical Academic Group, Maridulu Budyari Gumal (SPHERE), Sydney, Australia
- School of Physical Therapy, University of Western Ontario, London, Canada
- The Gray Centre for Mobility and Activity, Parkwood Institute, London, Canada
| | - Sean O'Neill
- Musculoskeletal Clinical Academic Group, Maridulu Budyari Gumal (SPHERE), Sydney, Australia
- South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Liverpool, Australia
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, St. Leonards, Australia
| | - Benedict M Wand
- Faculty of Medicine, Nursing & Midwifery and Health Sciences, The University of Notre Dame Australia, Fremantle, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
| | - Christopher M Williams
- University Centre for Rural Health, School of Health Sciences, University of Sydney, Lismore, Australia
| | - Ian A Harris
- Musculoskeletal Clinical Academic Group, Maridulu Budyari Gumal (SPHERE), Sydney, Australia
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, The University of New South Wales, Kensington, Australia
- Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, Australia
- Musculoskeletal Clinical Academic Group, Maridulu Budyari Gumal (SPHERE), Sydney, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Kensington, Australia
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18
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Duarte ST, Moniz A, Costa D, Donato H, Heleno B, Aguiar P, Cruz EB. Low back pain management in primary healthcare: findings from a scoping review on models of care. BMJ Open 2024; 14:e079276. [PMID: 38754873 PMCID: PMC11097853 DOI: 10.1136/bmjopen-2023-079276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services. OBJECTIVE To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP. DESIGN Scoping review. DATA SOURCES Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted. ELIGIBILITY CRITERIA Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings. DATA EXTRACTION AND SYNTHESIS Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach. RESULTS 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported. CONCLUSIONS This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
| | - Alexandre Moniz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Department of Physiotherapy, Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Bruno Heleno
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Pedro Aguiar
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
| | - Eduardo B Cruz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA University Lisbon, Lisboa, Portugal
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Trager RJ, Cupler ZA, Srinivasan R, Casselberry RM, Perez JA, Dusek JA. Chiropractic spinal manipulation and likelihood of tramadol prescription in adults with radicular low back pain: a retrospective cohort study using US data. BMJ Open 2024; 14:e078105. [PMID: 38692725 PMCID: PMC11086504 DOI: 10.1136/bmjopen-2023-078105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 04/15/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVES Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care. DESIGN Retrospective cohort study. SETTING US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023. PARTICIPANTS Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching. INTERVENTIONS Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care). PRIMARY AND SECONDARY OUTCOME MEASURES Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary). RESULTS After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts. CONCLUSIONS This study found that US adults initially receiving CSM for radicular LBP had a reduced likelihood of receiving a tramadol prescription over 1-year follow-up. These findings should be corroborated by a prospective study to minimise residual confounding.
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Affiliation(s)
- Robert James Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary A Cupler
- Physical Medicine & Rehabilitative Services, Butler VA Health Care System, Butler, Pennsylvania, USA
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Roshini Srinivasan
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Regina M Casselberry
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jaime A Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Maharjan P, Gelaw A, Griffiths D, Mazza D, Collie A. Use of General Practitioner Services Among Workers with Work-Related Low Back Pain: A Systematic Review. JOURNAL OF OCCUPATIONAL REHABILITATION 2024:10.1007/s10926-024-10187-x. [PMID: 38652423 DOI: 10.1007/s10926-024-10187-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Work-related low back pain (WRLBP) is a highly prevalent health problem worldwide leading to work disability and increased healthcare utilisation. General practitioners (GPs) play an important role in the management of WRLBP. Despite this, understanding of GP service use for WRLBP is limited. This systematic review aimed to determine the prevalence, patterns and determinants of GP service use for WRLBP. METHODS MEDLINE, Embase via Ovid, Scopus and Web of Science were searched for relevant peer-reviewed articles published in English without any restriction on time of publications. Low back pain (LBP) was considered work-related if the study included workers' compensation claim data analysis, participants with accepted workers' compensation claims or reported a connection with work and LBP. The eligibility criteria for GP service use are met if there is any reported consultation with family practitioner, medical doctor or General Practitioner. Two reviewers screened articles and extracted data independently. Narrative synthesis was conducted. RESULTS Seven eligible studies reported prevalence of GP service use among workers with WRLBP ranging from 11% to 99.3%. Only studies from Australia, Canada and the United States met the eligibility criteria. The prevalence of GP service use was higher in Australia (70%) and Canada (99.3%) compared to the United States (25.3% to 39%). The mean (standard deviation) number of GP visits ranged from 2.6 (1.6) to 9.6 (12.4) over a two-year time interval post-WRLBP onset. Determinants of higher GP service use included prior history of low back pain, more severe injury, prior GP visits and younger age. CONCLUSION Only seven studies met the eligibility indicating a relative lack of evidence, despite the acknowledged important role that GPs play in the care of workers with low back pain. More research is needed to understand the prevalence, patterns and determinants to support effective service delivery and policy development.
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Affiliation(s)
- Preeti Maharjan
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Asmare Gelaw
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Daniel Griffiths
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Danielle Mazza
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alex Collie
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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21
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Simula AS, Malmivaara A, Booth N, Karppinen J. Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial. J Rehabil Med 2024; 56:jrm28321. [PMID: 38643363 PMCID: PMC11151494 DOI: 10.2340/jrm.v56.28321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/03/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. DESIGN A benchmarking controlled trial design was used. SUBJECTS/PATIENTS Three primary healthcare areas and 654 low back pain patients with or without sciatica. METHODS Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. RESULTS No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003). Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of General
Medicine, Wellbeing services county of South Savo (ELOISA), Mikkeli, Finland.
| | - Antti Malmivaara
- Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedic Hospital, Helsinki, Finland
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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22
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Ho CL, Anantharaman V. Relevance of the Get Active Questionnaire for Pre-Participation Exercise Screening in the General Population in a Tropical Environment. Healthcare (Basel) 2024; 12:815. [PMID: 38667577 PMCID: PMC11050380 DOI: 10.3390/healthcare12080815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The Get Active Questionnaire (GAQ), developed by the Canadian Society for Exercise Professionals (CSEP), was recently recommended for pre-participation screening of the general population in Singapore before increasing their exercise levels. This literature review examines the evidence behind the GAQ and its relevance to our tropical environment. Searches were carried out via Pubmed, MEDLINE and the Cochrane Central Register of Controlled Trials. Resources referenced by the CSEPs were hand searched. The CSEP was also contacted for further information. The evidence behind each GAQ question was compared to international literature and guidelines, where applicable. Out of 273 studies, 49 were suitable for analysis. Two GAQ studies commissioned by the CSEP showed a high negative predictive value but high false negative rate. Of the nine GAQ questions, those on dizziness, joint pains and chronic diseases appear to be justified. Those on heart disease/stroke, hypertension, breathlessness and concussion require modification. The one on syncope can be amalgamated into the dizziness question. The remaining question may be deleted. No long-term studies were available to validate the use of the GAQ. Heat disorders were not considered in the GAQ. Modification of the GAQ, including the inclusion of environmental factors, may make it more suitable for the general population and should be considered.
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Affiliation(s)
- Cuiying Lisa Ho
- Department of Orthopaedic Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886, Singapore
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, Duke-NUS Academic Medical Centre, Outram Road, Singapore 169608, Singapore
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Thomas R, Gangathimmaiah V, Coates M, Guppy M. Editorial: Navigating low-value care in regional, rural and remote Australia. Aust J Rural Health 2024; 32:213-215. [PMID: 38646880 DOI: 10.1111/ajr.13123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- Rae Thomas
- Tropical Australian Academic Health Centre, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Vinay Gangathimmaiah
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
| | - Marlow Coates
- Office of Chief Executive, Torres and Cape Hospital and Health Service, Thursday Island, Queensland, Australia
| | - Michelle Guppy
- Australian Journal of Rural Health and School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
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24
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Mikkonen J, Kupari S, Tarvainen M, Neblett R, Airaksinen O, Luomajoki H, Leinonen V. To what degree patient-reported symptoms of central sensitization, kinesiophobia, disability, sleep, and life quality associated with 24-h heart rate variability and actigraphy measurements? Pain Pract 2024; 24:609-619. [PMID: 38087644 DOI: 10.1111/papr.13331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVES Chronic musculoskeletal pain is associated with decreased parasympathetic and increased sympathetic activity in the autonomic nervous system. The objective of this study was to determine the associations between objective measures of heart rate variability (a measure of autonomic nervous system function), actigraphy (a measure of activity and sleep quality), respiration rates, and subjective patient-reported outcome measures (PROMs) of central sensitization, kinesiophobia, disability, the effect of pain on sleep, and life quality. METHODS Thirty-eight study subjects were divided into two subgroups, including low symptoms of central sensitization (n = 18) and high symptoms of central sensitization (n = 20), based on patient-reported scores on the Central Sensitization Inventory (CSI). Heart rate variability (HRV) and actigraphy measurements were carried out simultaneously in 24 h measurement during wakefulness and sleep. RESULTS A decrease in HRV during the first 2 h of sleep was stronger in the low CSI subgroup compared to the high CSI subgroup. Otherwise, all other HRV and actigraphy parameters and subjective measures of central sensitization, disability, kinesiophobia, the effect of pain on sleep, and quality of life showed only little associations. DISCUSSION The high CSI subgroup reported significantly more severe symptoms of disability, kinesiophobia, sleep, and quality of life compared to the low CSI subgroup. However, there were only small and nonsignificant trend in increased sympathetic nervous system activity and poorer sleep quality on the high central sensitization subgroup. Moreover, very little differences in respiratory rates were found between the groups.
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Affiliation(s)
- Jani Mikkonen
- Private Practice, Helsinki, Finland
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Saana Kupari
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
| | - Mika Tarvainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
| | | | - Olavi Airaksinen
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hannu Luomajoki
- ZHAW School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Ville Leinonen
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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25
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O'Neill SFD, Nim C, Newell D, Leboeuf-Yde C. A new role for spinal manual therapy and for chiropractic? Part I: weaknesses and threats. Chiropr Man Therap 2024; 32:11. [PMID: 38532401 DOI: 10.1186/s12998-024-00531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024] Open
Abstract
Spinal manual therapy is central to chiropractic history, clinical practice, and professional identity. That chiropractors have developed an expertise in this domain has provided some considerable advantages. However, we contend it is also at the crux of the ideological schism that fractures the chiropractic profession. In this article, which is the first in a series of two, we discuss chiropractors' understanding and use of spinal manual therapy and do so with particular emphasis on what we see as weaknesses it creates and threats it gives rise to. These are of particular importance, as we believe they have limited the chiropractic profession's development. As we shall argue, we believe that these threats have become existential in nature, and we are convinced that they call for a resolute and unified response by the profession. Subsequently, in part II, we discuss various strengths that the chiropractic profession possesses and the opportunities that await, provided that the profession is ready to rise to the challenge.
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Affiliation(s)
- Søren Francis Dyhrberg O'Neill
- Medical Spinal Research Unit, Lillebaelt Hospital, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Østre Hougvej 55, Middelfart, Denmark.
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Casper Nim
- Medical Spinal Research Unit, Lillebaelt Hospital, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Østre Hougvej 55, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | | | - Charlotte Leboeuf-Yde
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Farrokhi S, Bechard L, Gorczynski S, Patterson C, Kakyomya J, Hendershot BD, Condon R, Perkins LTCM, Rhon DI, Delitto A, Schneider M, Dearth CL. The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization. Phys Ther 2024; 104:pzad173. [PMID: 38112119 DOI: 10.1093/ptj/pzad173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/10/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations. METHODS This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios. RESULTS Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy. CONCLUSION Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes. IMPACT Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits.
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Affiliation(s)
- Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Laura Bechard
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Sara Gorczynski
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Charity Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Kakyomya
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rachel Condon
- Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston, Texas, USA
| | - L T C Matthew Perkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher L Dearth
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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27
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Melman A, Teng MJ, Coombs DM, Li Q, Billot L, Lung T, Rogan E, Marabani M, Hutchings O, Maher CG, Machado GC. A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study. JMIR Res Protoc 2024; 13:e50146. [PMID: 38386370 PMCID: PMC10921332 DOI: 10.2196/50146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia. OBJECTIVE The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model. METHODS This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes. RESULTS As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024). CONCLUSIONS This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/50146.
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Affiliation(s)
- Alla Melman
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Min Jiat Teng
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
- RPA Virtual Hospital, Sydney Local Health District, Sydney, Australia
| | - Danielle M Coombs
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Eileen Rogan
- Department of Medicine, Canterbury Hospital, Sydney Local Health District, Sydney, Australia
| | - Mona Marabani
- Department of Medicine, Canterbury Hospital, Sydney Local Health District, Sydney, Australia
| | - Owen Hutchings
- RPA Virtual Hospital, Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
| | - Gustavo C Machado
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Australia
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28
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Bjørneboe J, Bratsberg A, Brox JI, Skatteboe S, Wilhelmsen M, Samuelsen KM, Marchand GH, Flørenes T, Kielland MG, Røe C. Symptom burden and follow-up of patients with neck and back complaints in specialized outpatient care: a national register study. Sci Rep 2024; 14:3855. [PMID: 38361115 PMCID: PMC10869734 DOI: 10.1038/s41598-024-53879-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/06/2024] [Indexed: 02/17/2024] Open
Abstract
Back and neck pain are common in the population, especially among immigrants. In Norway's specialist care system, treating these patients typically involves a multidisciplinary approach based on the biopsychosocial model. However, language and cultural differences may create barriers to participation. Immigrants are often underrepresented in clinical studies, but a register-based approach can enhance their participation in research. This study aimed to compare both the symptom burden, and treatment, among Norwegians, non-Norwegians, and patients requiring translator service for back and neck pain within the Norwegian specialist care system. The Norwegian neck and back registry is a National Quality Register, established in 2012 and fully digitized in late 2020. The baseline data includes demographics and patient recorded outcome measures including Oswestry Disability Index, Fear-Avoidance Beliefs, pain rating on a numeric rating scale, Hopkins Symptom Checklist and EuroQol five-dimensional questionnaire on health related quality of life. During the two-year study period, a total of 14,124 patients were invited, and 10,060 (71%) participated. Norwegian patients reported less pain, better function assessed by Oswestry Disability Index, lower fear avoidance beliefs, less emotional distress, and higher health related quality of life compared to non-Norwegians. We found that patients with female gender, who were younger, more educated and exhibited fear-avoidance behavior were significantly more likely to receive multidisciplinary treatment. We found no difference in the proportion of Norwegian and non-Norwegian patients receiving multidisciplinary treatment [odds ratio (OR) 1.02 (95% confidence interval (CI) 0.90-1.16)]. However, patients needing a translator were less likely to receive multidisciplinary treatment compared to those who didn't require translation [OR 0.41 (95% CI (0.25-0.66)]. We found that non-Norwegian patients experience a higher symptom burden compared to Norwegian. We found that both non-Norwegians and patient in need of translator were to a greater extent recommended treatment in primary health care. The proportion of non-Norwegians patients receiving multidisciplinary treatment was similar to Norwegians, but those needing a translator were less likely to receive such treatment.
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Affiliation(s)
- John Bjørneboe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.
| | - Andrea Bratsberg
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University in Oslo, Oslo, Norway
| | - Sigrid Skatteboe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Maja Wilhelmsen
- Department of Physical Medicine and Rehabilitation, University Hospital of North Norway, Tromsø, Norway
- Norwegian Neck and Back Registry, UNN Tromsø, Tromsø, Norway
| | - Kjetil Magne Samuelsen
- Department of Physical Medicine and Rehabilitation, University Hospital of North Norway, Tromsø, Norway
- Norwegian Neck and Back Registry, UNN Tromsø, Tromsø, Norway
| | - Gunn Hege Marchand
- Department of Physical Medicine and Rehabilitation, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tonje Flørenes
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Maja Garnaas Kielland
- Department of Health Care Coordination, Health Literacy and Health Equity, Oslo University Hospital, Oslo, Norway
| | - Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University in Oslo, Oslo, Norway
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Gomes LA, Rodrigues AM, van der Windt D, Pires D, Afreixo V, Canhão H, Cruz EB. Minimal Intervention of Patient Education for Low Back Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2024; 54:107-119. [PMID: 37970797 DOI: 10.2519/jospt.2023.11865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE: To explore the effects of minimal intervention of patient education (MIPE) for reducing disability and pain intensity in patients with low back pain (LBP). DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials. LITERATURE SEARCH: We searched the MEDLINE, Embase, CENTRAL, CINAHL, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Trials comparing MIPE, consisting of a single session of patient education, to no or other interventions in patients with LBP. DATA SYNTHESIS: Random effects meta-analysis was conducted where possible. A noninferiority margin of 5 points (0-100 scale) was considered for noninferiority hypotheses. We assessed risk of bias using the revised Cochrane risk-of-bias tool (RoB 2), and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. RESULTS: A total of 21 trials were included. There were no differences between MIPE and no intervention for effects on disability and pain intensity. There was low-certainty evidence that MIPE had inferior effects on short-term disability (mean difference = 3.62; 95% CI: 0.85, 6.38; 15 trials; n = 3066; I2 = 75%) and pain intensity (mean difference = 9.43; 95% CI: 1.31, 17.56; 10 trials; n = 1394; I2 = 90%) than other interventions. No differences were found for subsequent time points. CONCLUSION: As an intervention delivered in isolation, and without tailoring (ie, one-size-fits-all intervention), MIPE on average did not provide benefits for reducing disability and pain intensity over no or other interventions. We encourage clinicians to consider using additional/other or more tailored treatments when helping people manage LBP. J Orthop Sports Phys Ther 2024;54(2):1-13. Epub 16 November 2023. doi:10.2519/jospt.2023.11865.
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Najem C, Wijma AJ, Meeus M, Cagnie B, Ayoubi F, Van Oosterwijck J, De Meulemeester K, Van Wilgen CP. Facilitators and barriers to the implementation of pain neuroscience education in the current Lebanese physical therapist health care approach: a qualitative study. Disabil Rehabil 2024; 46:524-532. [PMID: 36655277 DOI: 10.1080/09638288.2023.2168076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. METHOD A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. RESULTS Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach." CONCLUSION The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach.IMPLICATIONS FOR REHABILITATIONThe exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management.The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.
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Affiliation(s)
- C Najem
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Department of physiotherapy, Faculty of Public Health, Antonine University, Hadath Baabda, Lebanon
- Pain in Motion International Research Group www. paininmotion.be
| | - A J Wijma
- Pain in Motion International Research Group www. paininmotion.be
- Transcare Transdisciplinary Pain Management Center, Groningen, the Netherlands
- PAIN - VUB Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium
| | - M Meeus
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Pain in Motion International Research Group www. paininmotion.be
- MOVANT Research group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - B Cagnie
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - F Ayoubi
- Department of physiotherapy, Faculty of Public Health, Antonine University, Hadath Baabda, Lebanon
- Department of physiotherapy, Faculty of Public Health, Lebanese University, Lebanon
| | - J Van Oosterwijck
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Pain in Motion International Research Group www. paininmotion.be
- MOVANT Research group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
- Research Foundation - Flanders (FWO), Belgium
| | - K De Meulemeester
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Pain in Motion International Research Group www. paininmotion.be
| | - C P Van Wilgen
- Pain in Motion International Research Group www. paininmotion.be
- Transcare Transdisciplinary Pain Management Center, Groningen, the Netherlands
- PAIN - VUB Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium
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Burton W, Salsbury SA, Goertz CM. Healthcare provider perspectives on integrating a comprehensive spine care model in an academic health system: a cross-sectional survey. BMC Health Serv Res 2024; 24:125. [PMID: 38263013 PMCID: PMC10804504 DOI: 10.1186/s12913-024-10578-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Healthcare systems (HCS) are challenged in adopting and sustaining comprehensive approaches to spine care that require coordination and collaboration among multiple service units. The integration of clinicians who provide first line, evidence-based, non-pharmacological therapies further complicates adoption of these care pathways. This cross-sectional study explored clinician perceptions about the integration of guideline-concordant care and optimal spine care workforce requirements within an academic HCS. METHODS Spine care clinicians from Duke University Health System (DUHS) completed a 26-item online survey via Qualtrics on barriers and facilitators to delivering guideline concordant care for low back pain patients. Data analysis included descriptive statistics and qualitative content analysis. RESULTS A total of 27 clinicians (57% response) responded to one or more items on the questionnaire, with 23 completing the majority of questions. Respondents reported that guidelines were implementable within DUHS, but no spine care guideline was used consistently across provider types. Guideline access and integration with electronic records were barriers to use. Respondents (81%) agreed most patients would benefit from non-pharmacological therapies such as physical therapy or chiropractic before receiving specialty referrals. Providers perceived spine patients expected diagnostic imaging (81%) and medication (70%) over non-pharmacological therapies. Providers agreed that receiving imaging (63%) and opioids (59%) benchmarks could be helpful but might not change their ordering practice, even if nudged by best practice advisories. Participants felt that an optimal spine care workforce would require more chiropractors and primary care providers and fewer neurosurgeons and orthopedists. In qualitative responses, respondents emphasized the following barriers to guideline-concordant care implementation: patient expectations, provider confidence with referral pathways, timely access, and the appropriate role of spine surgery. CONCLUSIONS Spine care clinicians had positive support for current tenets of guideline-concordant spine care for low back pain patients. However, significant barriers to implementation were identified, including mixed opinions about integration of non-pharmacological therapies, referral pathways, and best practices for imaging and opioid use.
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Affiliation(s)
- Wren Burton
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Osher Center for Integrative Health, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
| | - Christine M Goertz
- Implementation of Spine Health Innovations, Department of Orthopaedic Surgery, School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA.
- Duke Clinical Research Institute, Musculoskeletal Research, Duke University, 300 W. Morgan Street, Durham, NC, 27701, USA.
- Duke-Margolis Center for Health Policy, Duke University, 300 W. Morgan Street, Durham, NC, 27701, USA.
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Hansen AF, Hasle P, Caroly S, Reinhold K, Järvis M, Herrig AO, Heiberg BD, Søgaard K, Punnett L, Jensen Stochkendahl M. Participatory ergonomics: What works for whom and why? A realist review. ERGONOMICS 2024; 67:13-33. [PMID: 37070935 DOI: 10.1080/00140139.2023.2202842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/11/2023] [Indexed: 06/19/2023]
Abstract
Participatory workplace interventions to improve workforce musculoskeletal health are infrequently analysed regarding why they work, for whom or under what circumstances. This review sought to identify intervention strategies which achieved genuine worker participation. In total, 3388 articles on participatory ergonomic (PE) interventions were screened; 23 were suitable to analyse within a realist framework identifying contexts, mechanisms of change, and outcomes. The interventions which succeeded in achieving worker participation were characterised by one or more of these contexts: workers' needs as a core starting point; a positive implementation climate; clear distribution of roles and responsibilities; allocation of sufficient resources; and managerial commitment to and involvement in occupational safety and health. Interventions that were organised and delivered in this way generated relevance, meaning, confidence, ownership and trust for the workers in an interrelated and multi-directional manner. With such information, PE interventions may be carried out more effectively and sustainably in the future.Practitioner summary: This review focuses on the question: which mechanisms support genuine worker participation, in what context and with which necessary resources, to reduce musculoskeletal disorders. Results emphasise the importance of starting with workers' needs, making the implementation climate egalitarian, clarifying the roles and responsibilities of all involved, and providing sufficient resources.Abbreviations: PE: participatory ergonomic(s); WMSD: Work-related musculoskeletal disorders; EU: European Union; MSD: Muskuloskeletal disorders; OSH: Occupational health and safety; C: context; M: mechanism; O: outcome; CMOCs: CMO configurations; NPT: Normalization process theory; OECD: The Organisation for Economic Co-operation and Development: EU-OSHA: European Occupational Safety and Health Agency.
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Affiliation(s)
- Anne Faber Hansen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
- Department of Research and Education, University Library, University of Southern Denmark, Odense M, Denmark
| | - Peter Hasle
- Department of Technology and Innovation, SDU Global Sustainable Production, University of Southern Denmark, Odense M, Denmark
| | - Sandrine Caroly
- Pacte Laboratory- Grenoble Alpes University, Grenoble cedex 09, France
| | - Karin Reinhold
- Department of Business Administration, Tallinn University of Technology, Tallinn, Estonia
| | - Marina Järvis
- Department of Business Administration, Tallinn University of Technology, Tallinn, Estonia
- Estonian Entrepreneurship University of Applied Sciences, Tallinn, Estonia
| | - Astrid Overgaard Herrig
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Bibi Dige Heiberg
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Karen Søgaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Laura Punnett
- Center for the Promotion of Health in the New England Workplace (CPH-NEW), University of Massachusetts Lowell, Lowell, MA, USA
| | - Mette Jensen Stochkendahl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
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Iachina M, Wod M, Garvik OS, Schiøttz-Christensen B. Effect of surgery on the long-term use of opioids in patients with degenerative back disorders: a retrospective register-based study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:4444-4451. [PMID: 37650977 DOI: 10.1007/s00586-023-07901-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/11/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE This study based exclusively on register-data provides a scientific basis for further research on the use of opioids in patients with degenerative back disorder. The main objective of this study is to investigate whether surgically treated back pain patients have the same risk of being long-term opioid users as back pain patients who did not have surgery. METHODS We performed a retrospective register-based cohort study based on all patients diagnosed with a degenerative back disorder at the Spine Center of Southern Denmark from 2011 to 2017. The primary outcome of the study was the use of opioids two years after the patient's first hospital contact with a degenerative back condition. Fisher exact tests were used for descriptive analyses. The effect of the surgery was estimated using adjusted logistic regression analyses. RESULTS For patients who used opioids before the first hospital contact, the ratio for long-term opioid use for surgically treated patients is significantly lower than for non-surgically treated patients (OR = 0.75, 95%CI (0.66; 0.86)). For patients who did not use opioids before, the ratio for long-term opioid use for surgically treated patients does not differ from that of non-surgically treated patients (OR = 1.01, 95%CI (0.84; 1.22)). CONCLUSIONS Patients with a degenerative back disorder who used opioids before their first visit to a specialized spine center have a lower risk of becoming long-term opioid users if they were surgically treated. Whereas for patients who did not use opioids before the first visit, surgical treatment does not influence the risk of becoming long-term opioid users.
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Affiliation(s)
- M Iachina
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Sdr. Boulevard 29, entrance 219, ground floor, 5000, Odense, Denmark.
| | - M Wod
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Sdr. Boulevard 29, entrance 219, ground floor, 5000, Odense, Denmark
| | - O S Garvik
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, University of Southern Denmark, Sdr. Boulevard 29, entrance 219, ground floor, 5000, Odense, Denmark
| | - B Schiøttz-Christensen
- Spine Centre of Southern Denmark, Lillebaelt Hospital, University Hospital of Southern Denmark, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Archer L, Snell KIE, Stynes S, Axén I, Dunn KM, Foster NE, Wynne-Jones G, van der Windt DA, Hill JC. Development and External Validation of Individualized Prediction Models for Pain Intensity Outcomes in Patients With Neck Pain, Low Back Pain, or Both in Primary Care Settings. Phys Ther 2023; 103:pzad128. [PMID: 37756617 PMCID: PMC10682973 DOI: 10.1093/ptj/pzad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 05/05/2023] [Accepted: 07/14/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients with neck or low back pain in primary care settings. METHODS Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6 months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients' predictor information collected both at point of consultation and 2 to 4 weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance. RESULTS Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4 weeks after consultation (calibration slope = 0.848 [95% CI = 0.767 to 0.928] for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 [95% CI = 0.549 to 0.750]). CONCLUSION Model predictive accuracy was good when predictors were measured 2 to 4 weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance. IMPACT External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors.
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Affiliation(s)
- Lucinda Archer
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, UK
| | - Kym I E Snell
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, UK
| | - Siobhán Stynes
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Midlands Partnership Foundation NHS Trust, North Staffordshire Musculoskeletal Interface Service, Haywood Hospital, Staffordshire, UK
| | - Iben Axén
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, Stockholm, Sweden
| | - Kate M Dunn
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Nadine E Foster
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Hospital and Health Service, Queensland, Australia
| | | | | | - Jonathan C Hill
- School of Medicine, Keele University, Keele, Staffordshire, UK
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Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med 2023; 19:1961-1970. [PMID: 37259893 PMCID: PMC10620655 DOI: 10.5664/jcsm.10672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
STUDY OBJECTIVES To investigate the extent to which sleep measures are reported in intervention trials for chronic low back pain. METHODS A systematic scoping review was conducted. Ovid MEDLINE, Cochrane CENTRAL, and CINAHL were queried for trials published between January 2010 and December 2022 using keywords related to chronic low back pain. Two reviewers screened and reviewed abstracts and full texts for eligibility criteria and extracted data. Randomized intervention trials with the aim to treat pain or disability related to chronic low back pain in adults were included. Data were pooled and synthesized from trials that included a measure of sleep. RESULTS Two hundred eighty-two trials conducted in 40 different countries were included in the final review. Twenty-six trials (9.2%) assessed any sleep measure, and 13 (4.6%) collected a formal sleep disturbance measure at multiple time points. Three trials analyzed the mediating effects of sleep disturbance on pain. Reporting of sleep measures was no better in more recently published trials; trials published in 2010 (22%; n = 2/9) and 2022 (23%; n = 3/13) had the highest reporting rates. CONCLUSIONS The poor adherence to guideline recommendations for capturing measures of sleep quality or disturbance limits clinicians' and researchers' understanding of how sleep may influence treatment effects for chronic low back pain. There is an opportunity to improve the understanding of the relationship between sleep and pain with improved collection and reporting of sleep disturbance measures. CITATION Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med. 2023;19(11):1961-1970.
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Affiliation(s)
- Brett D Neilson
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
- Doctor of Physical Therapy Program, Hawai'i Pacific University, Honolulu, Hawaii
| | - Chris Dickerson
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Jodi L Young
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Mark H Shepherd
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Daniel I Rhon
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
- Department of Rehab Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
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Leech JB, MacPherson KL, Klopper M, Shumway J, Salvatori RT, Rhon DI, Young JL. The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study. PM R 2023; 15:1371-1381. [PMID: 37041723 DOI: 10.1002/pmrj.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice. OBJECTIVE To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge. DESIGN Retrospective cohort study. SETTING Hospital-based outpatient physical therapy. PARTICIPANTS Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis. MAIN OUTCOME MEASURES Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge. RESULTS A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region. CONCLUSION These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.
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Affiliation(s)
- Joseph B Leech
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Kevin L MacPherson
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- South College, School of Physical Therapy, Doctor of Physical Therapy Program, Atlanta, Georgia, USA
| | - Mareli Klopper
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Joshua Shumway
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Robert T Salvatori
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Daniel I Rhon
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Jodi L Young
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
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Tran DT, Lewin AM, Jorm L, Harris IA. Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross-sectional study. Med J Aust 2023; 219:303-309. [PMID: 37476970 PMCID: PMC10952263 DOI: 10.5694/mja2.52046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To investigate elective rates of spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions, by funding type (public, private, workers' compensation). DESIGN, SETTING Cross-sectional study; analysis of hospitals admissions data extracted from the New South Wales Admitted Patient Data Collection. PARTICIPANTS All adults who underwent elective spinal surgery (spinal fusion, decompression, disc replacement) in NSW, 1 July 2001 - 30 June 2020. MAIN OUTCOME MEASURES Crude and age- and sex-adjusted procedure rates, by procedure, funding type, and year; annual change in rates, 2001-20, expressed as incidence rate ratios (IRRs). RESULTS During 2001-20, 155 088 procedures in 129 525 adults were eligible for our analysis: 53 606 fusion, 100 225 decompression, and 1257 disc replacement procedures. The privately funded fusion procedure rate increased from 26.6 to 109.5 per 100 000 insured adults (per year: IRR, 1.06; 95% confidence interval [CI], 1.05-1.07); the workers' compensation procedure rate increased from 6.1 to 15.8 per 100 000 covered adults (IRR, 1.04; 95% CI, 1.01-1.06); the publicly funded procedure rate increased from 5.6 to 12.4 per 100 000 adults (IRR, 1.03; 95% CI, 1.01-1.06), and from 10.5 to 22.1 per 100 000 adults without hospital cover private health insurance (IRR, 1.03; 95% CI, 1.01-1.05). The privately funded decompression procedure rate increased from 93.4 to 153.6 per 100 000 people (IRR, 1.02; 95% CI, 1.01-1.03); the workers' compensation procedure rate declined from 19.7 to 16.7 per 100 000 people (IRR, 0.98; 95% CI, 0.96-0.99), and the publicly funded procedure rate did not change significantly. The privately funded disc replacement procedure rate increased from 6.2 per million in 2010-11 to 38.4 per million people in 2019-20, but did not significantly change for the other two funding groups. The age- and sex-adjusted rates for privately and publicly funded fusion and decompression procedures were similar to the crude rates. CONCLUSIONS Privately funded spinal surgery rates continue to be larger than for publicly funded procedures, and they have also increased more rapidly. These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need.
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Affiliation(s)
- Duong Thuy Tran
- Centre for Big Data Research in Healththe University of New South WalesSydneyNSW
| | | | - Louisa Jorm
- Centre for Big Data Research in Healththe University of New South WalesSydneyNSW
| | - Ian A Harris
- Centre for Big Data Research in Healththe University of New South WalesSydneyNSW
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical ResearchSydneyNSW
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Murillo C, Galán-Martín MÁ, Montero-Cuadrado F, Lluch E, Meeus M, Loh WW. Reductions in kinesiophobia and distress after pain neuroscience education and exercise lead to favourable outcomes: a secondary mediation analysis of a randomized controlled trial in primary care. Pain 2023; 164:2296-2305. [PMID: 37289577 DOI: 10.1097/j.pain.0000000000002929] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/02/2023] [Indexed: 06/10/2023]
Abstract
ABSTRACT Pain neuroscience education combined with exercise (PNE + exercise) is an effective treatment for patients with chronic spinal pain. Yet, however, little is known about its underlying therapeutic mechanisms. Thus, this study aimed to provide the first insights by performing a novel mediation analysis approach in a published randomized controlled trial in primary care where PNE + exercise was compared with standard physiotherapy. Four mediators (catastrophizing, kinesiophobia, central sensitization-related distress, and pain intensity) measured at postintervention and 3 outcomes (disability, health-related quality of life, and pain medication intake) measured at 6-month follow-up were included into the analysis. The postintervention measure of each outcome was also introduced as a competing candidate mediator in each respective model. In addition, we repeated the analysis by including all pairwise mediator-mediator interactions to allow the effect of each mediator to differ based on the other mediators' values. Postintervention improvements in disability, medication intake, and health-related quality of life strongly mediated PNE + exercise effects on each of these outcomes at 6-month follow-up, respectively. Reductions in disability and medication intake were also mediated by reductions in kinesiophobia and central sensitization-related distress. Reductions in kinesiophobia also mediated gains in the quality of life. Changes in catastrophizing and pain intensity did not mediate improvements in any outcome. The mediation analyses with mediator-mediator interactions suggested a potential effect modification rather than causal independence among the mediators. The current results, therefore, support the PNE framework to some extent as well as highlight the need for implementing the recent approaches for mediation analysis to accommodate dependencies among the mediators.
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Affiliation(s)
- Carlos Murillo
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | - Miguel Ángel Galán-Martín
- Unit for Active Coping Strategies for Pain in Primary Care, East-Valladolid Primary Care Management, Castilla and León Public Health System (Sacyl), Valladolid, Spain
| | - Federico Montero-Cuadrado
- Unit for Active Coping Strategies for Pain in Primary Care, East-Valladolid Primary Care Management, Castilla and León Public Health System (Sacyl), Valladolid, Spain
| | - Enrique Lluch
- Department of Physical Therapy, University of Valencia, Valencia, Spain
| | - Mira Meeus
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Wen Wei Loh
- Department of Data Analysis, Ghent University, Ghent, Belgium
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Shah S, Prakash V. Factors influencing physiotherapists implementation of high value care in the management of nonspecific low back pain in Indian healthcare settings: A qualitative study. Musculoskelet Sci Pract 2023; 67:102838. [PMID: 37556916 DOI: 10.1016/j.msksp.2023.102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Non-specific low back pain is a common musculoskeletal condition that often requires the involvement of physiotherapists for effective management. However, there is limited understanding of the factors influencing physiotherapists' implementation of high-value care in the management of non-specific low back pain (NSLBP), particularly in Indian healthcare settings. OBJECTIVE The aim of this study was to explore the barriers and facilitators of implementation of high-value care in managing NSLBP from the perspective of physiotherapists practicing in Indian healthcare settings. DESIGN Descriptive qualitative design. METHODS We adopted a descriptive phenomenological approach and purposefully selected physiotherapists (N = 15) from diverse healthcare settings, encompassing varying years of clinical experience, to capture a broad range of perspectives. Semi-structured face-to-face interviews were conducted via the Zoom video conferencing platform. Each interview lasted on average for 30-45 min, and no follow-up interviews were conducted. Data were analyzed using thematic analysis with an inductive approach. RESULTS Our analysis revealed three major themes and seven sub-themes uncovering barriers and facilitators of implementation of high-value care. These themes include misconceptions about low back pain and its management among physiotherapists, their perceived lack of autonomy in clinical decision-making due to external influences, and the significance of aligning treatment plans with patient goals while considering evidence-based care. CONCLUSION The study results provide insights into the unique challenges associated with implementation of high-value care for non-specific low back pain in Indian healthcare settings.
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Affiliation(s)
- Sweni Shah
- Ashok & Rita Patel Institute of Physiotherapy, Charotar University of Science and Technology, Changa, Anand, Gujarat, India.
| | - V Prakash
- Ashok & Rita Patel Institute of Physiotherapy, Charotar University of Science and Technology, Changa, Anand, Gujarat, India
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Lorio M, Lewandrowski KU, Coric D, Phillips F, Shaffrey CI. International Society for the Advancement of Spine Surgery Statement: Restorative Neurostimulation for Chronic Mechanical Low Back Pain Resulting From Neuromuscular Instability. Int J Spine Surg 2023; 17:728-750. [PMID: 37562978 PMCID: PMC10623686 DOI: 10.14444/8525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023] Open
Abstract
This International Society for the Advancement of Spine Surgery statement has been generated to respond to growing requests for background, supporting literature and evidence, and proper coding for restorative neurostimulation for chronic low back pain. Chronic low back pain describes the diverse experience of a significant proportion of the population. Conservative management of these patients remains the predominant care pathway, but for many patients, symptom relief is poor. The application of new techniques in patients who have exhausted traditional care paradigms should be undertaken with a detailed understanding of the pathology being treated, the mechanisms involved, and the data supporting efficacy. This statement on restorative neurostimulation places this technology in the context of the current understanding of the etiology of mechanical low back pain and the currently available evidence for this technique. In an appropriately selected cohort with a specific subset of chronic low back pain symptoms, this technique may provide benefit to payers and patients.
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Affiliation(s)
- Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, FL, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, The Surgical Institute of Tucson, Tucson, AZ, USA
- Department of Orthopedics, Fundación Universitaria Sanitas, Bogotá, DC, Colombia
- Department of Orthopedics Hospital Universitário Gaffre e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Domagoj Coric
- Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, NC, USA
| | - Frank Phillips
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Hill J, Kay D, Gordon J, Niazi IK, Saywell N. New Zealanders with low back pain seeking health care: a retrospective descriptive analysis of Accident Compensation Corporation-funded low back pain healthcare service usage. J Prim Health Care 2023; 15:206-214. [PMID: 37756237 DOI: 10.1071/hc23010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/09/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Most New Zealanders experience low back pain (LBP) at least once throughout their lifetime and many seek help from the large range of health providers in primary care. Accident Compensation Corporation (ACC) funds a significant proportion of those claims, but which services are they funding and what are the costs? Method This was a retrospective audit and descriptive analysis of ACC-funded, non-public hospital healthcare service use by people with LBP in New Zealand (NZ). Outcome measures were the healthcare services accessed by people with ACC-funded LBP,the claims (all occurrences for a service that has generated a payment/year), single contact (with a service), and costs (NZ$) for services between 2009 and 2020. Results The number of claims for services were 129 000 for physiotherapy, 105 000 for general practitioner and 59 000 for radiology services. Per single contact, elective surgery and radiology services were the most expensive. During 2009-2020, there were 3.3 million ACC claims for LBP with a total cost of NZ$4 billion. Over this time, there was an increase in claims, costs and single contacts. Costs decreased slightly during 2010 due to changes in healthcare funding and in 2020 due to the COVID-19 pandemic. Discussion Consumers have considerable choice in where they access health care for ACC-funded LBP services. This study shows the services they use most frequently and the cost to NZ for those services. These data can inform service planning for ACC-funded LBP health care in NZ.
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Affiliation(s)
- Julia Hill
- Department of Physiotherapy, School of Clinical Sciences, Active Living and Rehabilitation: Aotearoa New Zealand, Auckland University of Technology, New Zealand
| | - Dylan Kay
- Clinical Practice, Auckland, New Zealand
| | | | - Imran Khan Niazi
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; and Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand; and Research Innovation Centre, Auckland University of Technology, New Zealand
| | - Nicola Saywell
- Department of Physiotherapy, School of Clinical Sciences, Research Innovation Centre, Auckland University of Technology, New Zealand
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Lapin B, Li Y, Davin S, Stilphen M, Johnson JK, Benzel E, Habboub G, Katzan IL. Comparison of stratification techniques for optimal management of patients with chronic low back pain in spine clinics. Spine J 2023; 23:1334-1344. [PMID: 37149152 DOI: 10.1016/j.spinee.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND CONTEXT Identifying optimal stratification techniques for subgrouping patients with low back pain (LBP) into treatment groups for the purpose of identifying optimal management and improving clinical outcomes is an important area for further research. PURPOSE Our study aimed to compare performance of the STarT Back Tool (SBT) and 3 stratification techniques involving PROMIS domain scores for use in patients presenting to a spine clinic for chronic LBP. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Adult patients with chronic LBP seen in a spine center between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes (PROs) as part of routine care, and were followed up with completed PROs 1 year later. OUTCOME MEASURES Four stratification techniques, including SBT, and 3 PROMIS-based techniques: the NIH Task Force recommended Impact Stratification Score (ISS), symptom clusters based on latent class analysis (LCA), and SPADE symptom clusters. METHODS The 4 stratification techniques were compared according to criterion validity, construct validity, and prognostic utility. For criterion validity, overlap in characterization of mild, moderate, and severe subgroups were compared to SBT, which was considered the gold standard, using quadratic weighted kappa statistic. Construct validity compared techniques' ability to differentiate across disability groups defined by modified Oswestry LBP Disability Questionnaire (MDQ), median days in the past month unable to complete activities of daily living (ADLs), and worker's compensation using standardized mean differences (SMD). Prognostic utility was compared based on the techniques' ability to predict long-term improvement in outcomes, defined as improvement in global health and MDQ at 1-year. RESULTS There were 2,246 adult patients with chronic LBP included in our study (mean age 61.0 [SD 14.0], 55.0% female, 83.4% white). All stratification techniques resulted in roughly a third of patients grouped into mild, moderate, and severe categories, with ISS and LCA demonstrating substantial agreement with SBT, while SPADE had moderate agreement. Construct validity was met for all techniques, with large effects demonstrated between mild and severe categories for differentiating MDQ, ADLs, and worker's compensation disability groups (SMD range 0.57-2.48). All stratification techniques demonstrated ability to detect improvement by 1-year, with severe groups experiencing the greatest improvement in multivariable logistic regression models. CONCLUSIONS All 4 stratification techniques demonstrated validity and prognostic utility for subgrouping patients with chronic LBP based on risk of long-term disability. ISS and LCA symptom clusters may be the optimal methods given the improved feasibility of including only a few relevant PROMIS domains. Future research should investigate multidisciplinary treatment approaches to target mild, moderate, and severe patients based on these techniques.
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Affiliation(s)
- Brittany Lapin
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA.
| | - Yadi Li
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Sara Davin
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Mary Stilphen
- Department of Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Joshua K Johnson
- Department of Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Center for Value-Based Care Research, Community Care, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Edward Benzel
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Ghaith Habboub
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Irene L Katzan
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
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Olivier TJ, Konda C, Pham T, Baltich Nelson B, Patel A, Sharma GS, Trivedi K, Annaswamy TM. Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations. PM R 2023; 15:1052-1063. [PMID: 36507598 DOI: 10.1002/pmrj.12930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.
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Affiliation(s)
- Timothy J Olivier
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Chaitanya Konda
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Tri Pham
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Becky Baltich Nelson
- Clinical Library, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ankit Patel
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - G Sunny Sharma
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kavita Trivedi
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
- Physical Medicine & Rehabilitation Service, VA North Texas Health Care System, Dallas, Texas, USA
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Trager RJ, Cupler ZA, Srinivasan R, Casselberry RM, Perez JA, Dusek JA. Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data. BMJ Open 2023; 13:e073258. [PMID: 37479505 PMCID: PMC10364168 DOI: 10.1136/bmjopen-2023-073258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVES Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up. DESIGN Retrospective cohort study. SETTING US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023. PARTICIPANTS Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year. INTERVENTIONS Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES OR for gabapentin prescription. RESULTS After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference. CONCLUSIONS Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- College of Chiropractic, Logan University, Chesterfield, Missouri, USA
| | - Zachary A Cupler
- Physical Medicine & Rehabilitative Services, Butler VA Health Care System, Butler, Pennsylvania, USA
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Roshini Srinivasan
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Regina M Casselberry
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jaime A Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Rhon DI, Greenlee TA, Poehlein E, Beneciuk JM, Green CL, Hando BR, Childs JD, George SZ. Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2321929. [PMID: 37410465 PMCID: PMC10326636 DOI: 10.1001/jamanetworkopen.2023.21929] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/19/2023] [Indexed: 07/07/2023] Open
Abstract
Importance Tailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems. Objective To assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP. Design, Setting, and Participants This parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022. Interventions Risk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants' general practitioners and may have included a referral to physiotherapy. Main Outcomes and Measures The primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group. Results Analysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, -0.75 points; 95% CI -2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, -1.66 to 1.76 points). Conclusions and Relevance In this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03127826.
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Affiliation(s)
- Daniel I. Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
- Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, Maryland
| | - Tina A. Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jason M. Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville
- Brooks Rehabilitation Clinical Research Center, Jacksonville, Florida
| | - Cynthia L. Green
- Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Ben R. Hando
- Department of Orthopaedics and Rehabilitation, Wilford Hall Ambulatory Surgical Center, JBSA Lackland, Texas
| | | | - Steven Z. George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, School of Medicine, Durham, North Carolina
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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Gleadhill C, Dooley K, Kamper SJ, Manvell N, Corrigan M, Cashin A, Birchill N, Donald B, Leyland M, Delbridge A, Barnett C, Renfrew D, Lamond S, Boettcher CE, Chambers L, Maude T, Davis J, Hodgson S, Makaroff A, Wallace JB, Kotrick K, Mullen N, Gallagher R, Zelinski S, Watson T, Davidson S, Viana Da Silva P, Mahon B, Delore C, Manvell J, Gibbs B, Hook C, Stoddard C, Meers E, Byrne M, Schneider T, Bolsewicz K, Williams CM. What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia. BMJ Open 2023; 13:e071489. [PMID: 37328182 PMCID: PMC10277099 DOI: 10.1136/bmjopen-2022-071489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVES To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING Australian primary care. PARTICIPANTS Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.
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Affiliation(s)
- Connor Gleadhill
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- New South Wales Regional Health Partners, Newcastle, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Katherine Dooley
- School of Health Sciences, Charles Sturt University, Albury, New South Wales, Australia
| | - Steven J Kamper
- School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Allied Health Department, Nepean Blue Mountains Local Health District, Kingswood, New South Wales, Australia
| | - Nicole Manvell
- NUmoves Physiotherapy, Callaghan, New South Wales, Australia
| | | | - Aidan Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Noah Birchill
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Bruce Donald
- John Hunter Hospital Physiotherapy, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Murray Leyland
- Thornton Physiotherapy, Maitland, New South Wales, Australia
| | - Andrew Delbridge
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
| | | | - David Renfrew
- Newcastle Performance Physiotherapy, Newcastle, New South Wales, Australia
| | - Steven Lamond
- Newcastle Knights, Newcastle, New South Wales, Australia
| | - Craig Edward Boettcher
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
- Faculty of Medicine, The University of Sydney, Newcastle, New South Wales, Australia
| | - Lucia Chambers
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Travis Maude
- Advanced Physiotherapy, Warners Bay, New South Wales, Australia
| | - Jon Davis
- PhysioStudio, Maitland, New South Wales, Australia
| | - Stephanie Hodgson
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Andrew Makaroff
- Employers Mutual Limited, Newcastle, New South Wales, Australia
| | | | - Kelly Kotrick
- Newcastle Performance Physiotherapy, Newcastle, New South Wales, Australia
| | | | - Ryan Gallagher
- Honeysuckle Health, Newcastle, New South Wales, Australia
| | - Samuel Zelinski
- NUmoves Physiotherapy, Callaghan, New South Wales, Australia
| | - Toby Watson
- The Good Physio, Newcastle, New South Wales, Australia
| | - Simon Davidson
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Priscilla Viana Da Silva
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | | | - Caitlin Delore
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
| | - Joshua Manvell
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | | | - Chris Hook
- Advanced Physiotherapy, Warners Bay, New South Wales, Australia
| | - Chris Stoddard
- Terrace Physio Plus, Raymond Terrace, New South Wales, Australia
| | - Elliot Meers
- Kinetic Sports Physiotherapy, Newcastle, New South Wales, Australia
| | - Michael Byrne
- Recovery Partners, Newcastle, New South Wales, Australia
| | | | - Katarzyna Bolsewicz
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- National Centre for Immunisation Research and Surveillance, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Christopher Michael Williams
- School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Mid North Coast Local Health District, Port Macquarie, New South Wales, Australia
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O'Hagan ET, Wallwork SB, Callander E, Stanton TR, Mychasiuk R. The Foundations for Chronic Low Back Pain Management may Start in Early Life. Exploring the Role of Caregiver Parental Leave on Future Low Back Pain in the Offspring. THE JOURNAL OF PAIN 2023; 24:939-945. [PMID: 36646402 DOI: 10.1016/j.jpain.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/02/2023] [Accepted: 01/07/2023] [Indexed: 01/15/2023]
Abstract
Chronic low back pain is difficult to treat and despite increased spending on health services, clinical outcomes for people with low back pain have not improved. Innovative, large scale initiatives seem necessary to stem the cost of low back pain. Psychological health contributes to the development and persistence of chronic low back pain and psychological interventions are important in the management of low back pain. Given the contribution of psychological health to low back pain development and management, it raises the question; can we support psychological health in later life by bolstering emotional development in early life, and reduce the burden of this common condition? Positive early life experiences, including those induced by extended paid parental leave, could bolster emotional development and support the psychological health necessary to manage low back pain in later life. We present the current state of evidence demonstrating the potential value of increasing support for parent-child relationships in early life to reduce the burden of low back pain in future generations. The current evidence is limited to cross-sectional associations, but strong preclinical data clearly shows the potential negative impacts of maternal separation on rodent pup health that compels consideration in human populations. PERSPECTIVE: The benefits stemming from enhanced child development include stable emotional foundations, possibly improving psychological health and low back pain management in the future. This perspective raises questions for future studies - within the context of low back pain, what ingredients bolster stable psychological health? And are these ingredients influenced by parental leave?
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Affiliation(s)
- Edel T O'Hagan
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Sarah B Wallwork
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Sydney, NSW, Australia
| | - Emily Callander
- Monash Centre for Health Research and Implementation (MCHRI), School of Public Health and Preventative Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Tasha R Stanton
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Sydney, NSW, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, Clayton, VIC, Australia
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49
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Czaplewski LG, Rimmer O, McHale D, Laslett M. Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability. J Orthop Surg Res 2023; 18:351. [PMID: 37170132 PMCID: PMC10176889 DOI: 10.1186/s13018-023-03839-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/07/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Estimating the contribution of endplate oedema known as Modic changes to lower back pain (LBP) has been the subject of multiple observational studies and reviews, some of which conclude that the evidence for an association of Modic change with LBP is uncertain while others demonstrate a clear link. The clinical trials demonstrating the benefit of basivertebral nerve ablation, a therapeutic intervention, in a tightly defined homogenous patient group with chronic LBP and Modic changes type 1 or type 2, provides further evidence for the contribution of Modic changes to LBP and shows that in these subjects, nerve ablation substantially reduces pain and disability. These interventional studies provide direct evidence that Modic changes can be associated with lower back pain and disability. This review set out to explore why the literature to date has been conflicting. METHODS A narrative, forensic, non-systematic literature review of selected articles to investigate why the published literature investigating the association between Modic imaging changes and chronic low back pain is inconsistent. RESULTS This review found that previous systematic reviews and meta-analyses included both heterogeneous study designs and diverse patient syndromes resulting in an inconsistent association between Modic changes and nonspecific chronic lower back pain. Re-analysis of literature data focussing on more homogenous patient populations provides clearer evidence that Modic changes are associated with nonspecific chronic lower back pain and that type 1 Modic changes are more painful than type 2. CONCLUSIONS Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2 Modic changes with pain and disability.
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Affiliation(s)
- Lloyd G Czaplewski
- Persica Pharmaceuticals Ltd, 7 Denne Hill Business Centre, Womenswold, Canterbury, Kent, CT4 6HD, UK.
| | - Otis Rimmer
- Veramed Ltd, 5th Floor Regal House, 70 London Road, Twickenham, TW1 3QS, UK
| | | | - Mark Laslett
- Mark Laslett, Physiotherapy Specialist, The Sports Clinic, 156 Bealey Ave., Christchurch, 8014, New Zealand
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Mikkonen J, Luomajoki H, Airaksinen O, Goubert L, Leinonen V. Protocol of identical exercise programs with and without specific breathing techniques for the treatment of chronic non-specific low back pain: randomized feasibility trial with two-month follow-up. BMC Musculoskelet Disord 2023; 24:354. [PMID: 37147638 PMCID: PMC10161472 DOI: 10.1186/s12891-023-06434-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/15/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Chronic low back pain (CLBP) is a leading cause of disability globally. Exercise therapies are one of the commonly prescribed treatment options for CLBP. The specific exercise therapies for CLBP most commonly target movement dysfunction, but seldom brain-based pain modulation. Exercise therapies with specific breathing techniques (SBTs) have been shown to influence and enhance brain-based structural and functional pain modulation. AIMS AND OBJECTIVES To assess the feasibility of the SBTs protocol, eligibility criteria, randomization, and dropout rates. To quantify the changes in patient outcome measures and choose the most relevant measure for larger-scale study. To quantify self-adherence levels to home exercise and monitor and record possible pain medication and other treatment modality usage, and adverse events during exercise. DESIGN A parallel randomised analyst-blinded feasibility trial with two-month follow-up. OUTCOME MEASURES Feasibility related to aims and objectives. Multiple pain- and health-related patient-reported outcome measures of pain intensity, disability, central sensitization, anxiety, kinesiophobia, catastrophising, self-efficacy, sleep quality, quality of life, and health and well-being status. Exercise adherence, pain medication and other treatment modality usage, and possible adverse events related to exercises will be monitored and recorded. METHODS Thirty participants will be randomized to movement control exercise with SBTs (15 subjects in experimental group) or movement control exercise without SBTs (15 subjects in control group) in private chiropractic practice setting with two-month follow-up. Trial registration number; NCT05268822. DISCUSSION The clinical difference in effectiveness between practically identical exercise programs in uniform study settings with or without SBTs has not been studied before. This study aims to inform feasibility and help determine whether progression to a full-scale trial is worthwhile.
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Affiliation(s)
- Jani Mikkonen
- Private Practice, Mikonkatu 11, 00100, Helsinki, Finland.
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, 70211, Kuopio, Finland.
| | - Hannu Luomajoki
- ZHAW School of Health Professions, Zurich University of Applied Sciences, CH-8401, Winterthur, Switzerland
| | - Olavi Airaksinen
- Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, 70211, Kuopio, Finland
| | - Liesbet Goubert
- Department of Experimental-Clinical and Health Psychology, Ghent University, 9000, Ghent, Belgium
| | - Ville Leinonen
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, 70211, Kuopio, Finland
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