Back to basics: 10 facts every person should know about back pain

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

How do people with chronic low back pain perceive specific and general exercise? A mixed methods survey

PURPOSE

Exercise prescriptions for chronic low back pain (CLBP) often utilize reductionistic, trunk-focused exercise aimed at addressing proposed pain mechanisms. It is unknown if the use of these trunk-focused exercises imply beliefs to people with CLBP about the rationale for their use (e.g., etiology), even without concurrent biomedical narratives. This study aimed to explore people's perceptions of specific and general exercise without an accompanying narrative when experiencing CLBP.

METHODS

An anonymous online survey was distributed. Mixed methods were utilized for analysis. Six-point Likert scales categorized people's beliefs about individual exercises. Open-ended questions were used to gather further beliefs which were then coded into themes.

RESULTS

People with CLBP perceived specific exercise as more beneficial than general exercise. Eight themes and five subthemes were defined. A high volume of positive beliefs were centered around strengthening the low back and abdominal musculature, emphasizing the importance of correct technique. Negative beliefs were held against spinal flexion and external load. Both positive and negative beliefs were underpinned by spinal/pelvic stability being important as well as certain exercises being achievable or not.

CONCLUSION

This study demonstrated that people with CLBP consider specific exercises to be more beneficial than general exercises for CLBP. Specific exercises irrespective of an accompanying narrative can imply meaning about the intent of an exercise. Understanding this requires practitioners to be mindful when prescribing and communicating exercise.

Alterations in Circadian Rhythms, Sleep, and Physical Activity in COVID-19: Mechanisms, Interventions, and Lessons for the Future

Although the world is acquitting from the throes of COVID-19 and returning to the regularity of life, its effects on physical and mental health are prominently evident in the post-pandemic era. The pandemic subjected us to inadequate sleep and physical activities, stress, irregular eating patterns, and work hours beyond the regular rest-activity cycle. Thus, perturbing the synchrony of the regular circadian clock functions led to chronic psychiatric and neurological disorders and poor immunological response in several COVID-19 survivors. Understanding the links between the host immune system and viral replication machinery from a clock-infection biology perspective promises novel avenues of intervention. Behavioral improvements in our daily lifestyle can reduce the severity and expedite the convalescent stage of COVID-19 by maintaining consistent eating, sleep, and physical activity schedules. Including dietary supplements and nutraceuticals with prophylactic value aids in combating COVID-19, as their deficiency can lead to a higher risk of infection, vulnerability, and severity of COVID-19. Thus, besides developing therapeutic measures, perpetual healthy practices could also contribute to combating the upcoming pandemics. This review highlights the impact of the COVID-19 pandemic on biological rhythms, sleep-wake cycles, physical activities, and eating patterns and how those disruptions possibly contribute to the response, severity, and outcome of SARS-CoV-2 infection.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Are there any correlations among the number of discopathy levels and pain intensity or disability in patients with symptomatic low back pain?

INTRODUCTION

Low back pain (LBP) is considered a civilization disease that affects people in an increasing number. Discopathy (degeneration of intervertebral discs) is recognised as one of LBP causes. Still, the relationship between the number of discopathy levels and LBP remains unclear. The aim of this study was to evaluate the correlation between the number of discopathy levels with intensity of LBP, functional level and the degree of disability.

MATERIALS AND METHODS

The prospective, cohort study involved 200 patients aged 27 to 55 years (44.9 ± 9.2 years) with single- or multilevel lumbar discopathy confirmed by imaging examinations. Functional examination included NRSscale, goniometric measurements, Modified Laitinen Pain Questionnaire, Oswestry Disability Index and Back Pain Function Scale.

RESULTS

There were statistically significant positive correlations between the number of discopathy levels and the age of the subjects (r = 0.266; p = 0.000), BMI (r = 0.158; p = 0.029) and ODI (r = 0.157; p = 0.026). Positive correlation (r = 0.142; p = 0.044) was also observed between the results of Fingertip-to-floortest and the number of levels of discopathy.

CONCLUSIONS

The number of levels of discopathy was depended on the age and BMI of the patients. It had no effect on pain intensity, range of rotational motion of the lumbar spine and functional status of patients. As the number of levels of discopathy increased, a higher degree of everyday disability was observed.

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

BACKGROUND

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

OBJECTIVE

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of 'root causes' for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

CONCLUSIONS

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

Associations between psychological factors, pressure pain thresholds and conditioned pain modulation and disability in (sub)-acute low back pain: a three-month follow-up study

BACKGROUND

The clinical presentation and pain experience of patients with (sub)-acute low back pain ((S)ALBP) can strongly vary in clinical practice. However, despite growing evidence that psychological factors are associated with disability in chronic pain conditions including low back pain, studies examining the influence of psychological factors, quantitative sensory testing (QST) (i.e. pressure pain thresholds (PPTs)) and conditioned pain modulation (CPM) on future disability are still lacking in (S)ALBP.

OBJECTIVE

This prospective cohort study aims to determine associations between baseline psychological factors, PPTs and CPM in (S)ALBP and disability after 3 months.

METHODS

Fifty-two patients with (S)ALBP underwent a baseline PPT evaluation in rest and during a CPM protocol. Patients were asked to fill in self-report questionnaires: the Visual Analogue Scale (VAS), the Quebec Back Pain Disability Scale (QBPDS), the Pain Catastrophizing Scale (PCS), the Tampa Scale for Kinesiophobia (TSK) and the Illness Perception Questionnaire - Brief version (IPQ-B). At 3-month follow-up, participants were asked to fill in the QBPDS again. Multiple linear regression analysis was conducted to determine associations between baseline factors and disability at follow-up.

RESULTS

Thirty-eight patients participated at follow-up. Because of the multicollinearity issue, the TSK score was selected for analyses and the PCS and IPQ-B score were excluded from the model. No significant associations between baseline factors and disability at follow-up were found.

CONCLUSION

Neither baseline psychological factors nor PPTs or CPM in (S)ALBP were significantly associated with disability after 3 months. Our multiple linear regression analysis was likely underpowered to detect significant associations.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Effectiveness of a Group-Based Rehabilitation Program Combining Education with Multimodal Exercises in the Treatment of Patients with Nonspecific Chronic Low Back Pain: A Retrospective Uncontrolled Study

Currently, there is no consensus on the best rehabilitation program to perform for nonspecific chronic low back pain (NSCLBP). However, multimodal exercises, education, and group-based sessions seem to be beneficial. We, therefore, launched such a treatment program and aimed to evaluate its effectiveness in improving patient health status. We retrospectively analyzed the records of 23 NSCLB patients who followed the MyBack program at La Tour hospital from 2020 to 2022 (25 sessions, 8 weeks). Patients were evaluated before and after intervention using pain on a visual analog scale (pVAS), Roland−Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and the EuroQol-5D-3L (EQ-5D-3L). Responder rates were calculated using minimal clinically important differences. Patients reported a significant reduction (p < 0.05) in the pVAS (5.3 ± 1.2 vs. 3.1 ± 1.6), RMDQ (8.8 ± 3.3 vs. 4.0 ± 3.7), PCS (24.5 ± 9.4 vs. 11.7 ± 7.9) and TSK (41.5 ± 9.2 vs. 32.7 ± 7.0). The EQ-5D-3L also statistically improved (score: 0.59 ± 0.14 vs. 0.73 ± 0.07; and VAS: 54.8 ± 16.8 vs. 67.0 ± 15.2). The responder rates were 78% for the pVAS and PCS, 74% for the RMDQ and TSK, and only 26% for the EQ-5D-3L. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.

"Myths and Facts" Education Is Comparable to "Facts Only" for Recall of Back Pain Information but May Improve Fear-Avoidance Beliefs: An Embedded Randomized Trial

OBJECTIVE

To assess the effectiveness of patient education with "myths and facts" versus "facts only" on recall of back pain information and fear-avoidance beliefs in patients with chronic low back pain (LBP).

DESIGN

Randomized Study Within A Trial.

METHODS

One hundred fifty-two participants with chronic LBP were included. Participants allocated to the "facts only" group received an information sheet with 6 LBP facts, whereas those allocated to the "myths and facts" group received the same information sheet, with each myth refuted by its respective fact. The primary outcome was a correct recall of back pain facts, and the secondary outcome was the physical activity component of the Fear-Avoidance Beliefs Questionnaire (FABQ-PA), 2 weeks after the provision of the information sheet.

RESULTS

There was no evidence of a difference in the proportion of participants with a correct recall between the "myths and facts" and "facts only" groups (odds ratio = 0.98; 95% confidence interval [CI]: 0.48, 1.99) and no significant difference in FABQ-PA mean scores between groups (-1.58; 95% CI: -3.77, 0.61). Sensitivity analyses adjusted for prognostic factors showed no difference in information recall but a larger difference in FABQ-PA scores (-2.3; 95% CI: -4.56, -0.04).

CONCLUSION

We found no overall difference in the recall of back pain information for patients provided with "myths and facts" compared with that for patients provided with "facts only" and a slight reduction in fear-avoidance beliefs for physical activity using "myths and facts" compared with that using "facts only," but the meaningfulness of this result is uncertain. J Orthop Sports Phys Ther 2022;52(9):586-594. Epub: 9 July 2022. doi:10.2519/jospt.2022.10989.

Risk Factors for Back Pain among Southern Brazilian School Children: A 6-Year Prospective Cohort Study

Risk factors associated with back pain vary in different countries. Given the lack of studies in Latin America, our study aimed to assess back pain and its associated factors for six years in Southern Brazilian school children. All children attending the fifth grade of Teutônia, Brazil, were invited to participate in the study. Only schoolchildren who did not report back pain were included in the first assessment. The schoolchildren completed the Back Pain and Body Posture Evaluation Instrument (BackPEI) during three assessments (2011, 2014, and 2017). BackPEI assesses the presence of back pain and possible associated risk factors (postural, behavioral, and sociodemographic). Generalized estimated equations (GEE) were used to perform a Poisson regression model with robust variance for longitudinal analysis. After six years of follow-up, 75 schoolchildren completed all the assessments. The risk factors associated with back pain were spending more than six hours daily watching television, lifting objects from the ground adopting an inadequate posture, using another backpack type different from those with two straps, and carrying a backpack in an asymmetric way. These results are important in guiding the planning of public policies to minimize this public health problem.

Efficacy and tolerability of the antispasmodic, pridinol, in patients with muscle-pain - results of primepain, a retrospective analysis of open-label real-world data provided by the German pain E-registry

OBJECTIVE

To evaluate efficacy and tolerability of the nonbenzodiazepine antispasmodic pridinol (PRI), as an add-on treatment in patients with muscle-related pain (MRP).

METHODS

Exploratory retrospective analysis of depersonalized routine data provided by the German Pain e-Registry (GPeR) focusing on pain intensity, pain-related disabilities in daily life, wellbeing, and drug-related adverse events (DRAEs).Primary endpoint based on a global response composite of (a) a clinically relevant analgesic response (relative improvement ≥50% and/or absolute improvement ≥ the minimal clinical important difference) for pain intensity and disability in combination with (b) an improvement in wellbeing (all at end of treatment vs. baseline), and (c) lack of any DRAEs.

RESULTS

Between 1 January 2018 and 31 December 2020, the GPeR collected information on 121,803 pain patients of whom 1133 (0.9%; 54.5% female, mean ± SD age: 53.9 ± 11.8 years) received add-on PRI for the treatment of (mostly acute) MRP originating predominantly in the (lower) back (43.2%), lower limb (26.4%), or should/neck (21.1%). Average daily dose was 7.8 ± 1.8 (median 9, range 1.5-13.5) mg, duration of treatment 12.0 ± 10.2 (median 7, range 3-63) days. In total, 666 patients (58.8%) reported a complete, 395 (34.9%) a partial, and 72 (6.4%) patients no response - either because of lack of efficacy (n = 2, 0.2%) or DRAEs (n = 70, 6.2%). In response to PRI, 41.7% of patients documented a reduction of at least one other pain medication and 30.8% even the complete cessation of any other pharmacological pain treatments.

CONCLUSION

Based on this real-world data of the German Pain e-Registry, add-on treatment with PRI in patients with acute MRP under real-world conditions in daily life was well tolerated and associated with an improvement of pain intensity, pain-related disabilities, and overall wellbeing.

Which psychosocial factors are related to severe pain and functional limitation in patients with low back pain?: Psychosocial factors related to severe low back pain

BACKGROUND

Low back pain (LBP) is a global public health issue. Psychosocial factors are linked to LBP. However, there is a lack of knowledge about the relation of psychosocial factors to clinical outcomes of patients with severe LBP.

OBJECTIVE

To investigate the relationship between specific psychosocial factors with severe pain and functional limitation of patients with LBP.

METHODS

A cross-sectional study of 472 participants with LBP was conducted. Participants completed self-reported questionnaires, including psychosocial factors, characteristics of pain, and functional limitations. Two multivariable logistic regression models were performed with severe pain intensity (≥ 7 out of 10) and functional limitation (≥ 7 out of 10) (dependent variables) and 15 psychosocial factors (independent variables).

RESULTS

One hundred twenty-five (26.5%) participants had severe LBP. Patients with catastrophising symptoms were 2.21 [95%Confidence Interval (CI): 1.30, 3.77] times more likely to have severe pain and 2.72 (95%CI: 1.75, 4.23) times more likely to have severe functional limitation than patients without catastrophising symptoms. Patients with maladaptive beliefs about rest were 2.75 (95%CI: 1.37, 5.52) times more likely to present with severe pain and 1.72 (95%CI: 1.04, 2.83) times more likely to have severe functional limitation. Patients with kinesiophobia were 3.34 (95%CI: 1.36, 8.24) times more likely to present with severe pain, and patients with social isolation were 1.98 (95%CI: 1.25, 3.14) times more likely to have severe functional limitation.

CONCLUSION

Catastrophising, kinesiophobia, maladaptive beliefs about rest, and social isolation are related to unfavourable clinical outcomes of patients with LBP.

The detrimental impact of temporomandibular disorders (mis)beliefs and possible strategies to overcome

AIM

This topical review presents common patients' misbeliefs about temporomandibular disorders (TMD) and discusses their possible impact on the diagnosis, treatment and prognosis. We also discussed the possible influence of the beliefs and behaviors of health care providers on the beliefs of patients with TMD and present possible strategies to overcome the negative impacts of such misbeliefs.

METHODS

This topical review was based on a non-systematic search for studies about the beliefs of patients and professionals about TMD in PubMed and Embase.

RESULTS

Patients' beliefs can negatively impact the diagnosis, treatment, and prognosis of TMD. These beliefs can be modulated by several factors such as culture, psychosocial aspects, gender, level of knowledge, and previous experiences. Moreover, primary health care professionals, including dentists, may lack sufficient experience and skills regarding TMD diagnosis and treatment. Misbeliefs of the health care professionals can be based on outdated evidence that is not supported by rigorous methodological investigations. Education and dissemination of knowledge to patients and the general population are effective for prevention, promotion of health and disruption of the cycle of misinformation and dissemination of misbeliefs.

CONCLUSION

The lack of basic information about TMD and the dissemination of mistaken and outdated concepts may delay the diagnosis, hinder the treatment, and consequently increase the risk of worsening the condition. Education is key to overcome TMD misbeliefs.

Factors associated with the low back pain-related attitudes and beliefs of physical therapists

BACKGROUND

Clinicians who believe in a strong connection between pain and disability, and who have biomedically oriented beliefs recommend less physical activity, more time off work, and promote unhelpful beliefs in patients. Understanding how these beliefs develop may assist in identifying ways to reduce unhelpful beliefs in clinicians.

OBJECTIVE

To identify factors that are associated with the LBP-related attitudes and beliefs of US-based physical therapists.

DESIGN

Cross-sectional design METHOD: An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), pain science knowledge was measured using the Neurophysiology of Pain Questionnaire (NPQ), and professional and demographic information were collected.

RESULTS

Completed surveys were obtained from 420 physical therapists. More helpful attitudes and beliefs were associated with board certification in orthopedics or sports, higher NPQ scores, and working in a hospital-based clinic. Less helpful attitudes and beliefs were associated with working in private practice and a personal history of LBP that had a minimum or significant impact on life. The factors included in this study explained 16.8% of the variability in HC-PAIRS scores (p < .001), 13% of the variability in PABS-BM scores (p < .001), and 8.3% of the variability in PABS-BPS scores (p < .001).

CONCLUSION

Several modifiable and non-modifiable factors are associated with the LBP-related attitudes and beliefs of US physical therapists.

Can a Brief Online Interdisciplinary Program Enhance the Understanding of Musculoskeletal Pain amongst Primary Care Staff? A Prospective Study

Background

Primary care staff do not provide consistent education on musculoskeletal pain management to patients in accordance with the recommendations of clinical practice guidelines. We have developed a concise online learning program to bridge this gap.

Objectives

To investigate (1) the effectiveness of 1-hour musculoskeletal pain neurophysiology education program conducted by a physiotherapist on primary care staff; (2) the correlation between demographic factors of staff and the interdisciplinary learning performances.

Methods

We piloted a multicenter single-blind prospective study on sixty-four staff from the pharmacy department in eight public primary care clinics. Participants in the intervention group attended the 1-hour online program compared to a control group. The Neurophysiology of Pain Questionnaire (NPQ) to assess learning and the 10-point Likert scale program evaluation form to assess learning reaction of participants after the program were used.

Results

The participants reacted positively to the online learning program. The intervention group significantly improved in their musculoskeletal pain knowledge by a greater mean NPQ score difference 2.39 ( p < 0.001) compared with the control group. There were poor correlations between the demographic factors and their learning.

Conclusion

The pilot study shows that primary care staff may still utilize a biomedical approach in managing musculoskeletal pain. The improvement in knowledge demonstrates that short online programs could be a valuable part of interdisciplinary education in primary care because it is easily accessible by healthcare professionals and can benefit other healthcare staff regardless of their background.

[Patient education for acute low back pain : Contents of pain education in patients with acute non-specific low back pain - a scoping review]

OBJECTIVE

The objective of the review is to map the content of intervention education in people with acute nonspecific lumbar low back pain (LBP) to make it available in a synopsis.

BACKGROUND

In the care of people with acute non-specific LBP, education is recommended as an elementary treatment component. However, the proposed content is proving to be heterogenic and the question arises as to how education should be designed in the future.

METHOD

A systematic literature search and content analysis of studies with content on pain education was conducted as part of a scoping review. Inclusion criteria were: provision of relevant information on the content of pain education, patients with acute nonspecific low back pain, 18 years or older, publication in English or German. The search was conducted in the Medline, CINAHL, Cochrane Library, and PEDro databases and supplemented by a hand search. The search was completed in February 2021.

RESULTS

A total of 4239 hits were identified, of which 90 studies were included. A wide range of content was found and clustered into ten categories. The most frequent statements were in the categories "recommendations for dealing with LRS," "education, reassuring aspects, and relieving basic messages," and "information and recommendations about medications."

CONCLUSION

The teaching of pathoanatomical information can potentially trigger or increase anxiety and worry, whereas information on neurophysiological mechanisms of pain development and processing is more likely to have an anxiety-reducing effect. The results can contribute to the design of the intervention in different settings.

Sa12b Improves Biological Activity of Human Degenerative Nucleus Pulposus Mesenchymal Stem Cells in a Severe Acid Environment by Inhibiting Acid-Sensitive Ion Channels

Sa12b is a wasp peptide that can inhibit acid-sensitive ion channels (ASICs). The biological effects of nucleus pulposus mesenchymal stem cells (NP-MSCs) have not been investigated. Therefore, this study investigated the effect of Sa12b on the biological activity of NP-MSCs through ASICs in the acidic environment of intervertebral disc degeneration (IVDD). In this study, NP-MSCs were isolated from the nucleus pulposus (NP) in patients who underwent lumbar disc herniation surgery, identified by flow cytometry and tertiary differentiation, and cultured in vitro in an acidic environment model of IVDD with a pH of 6.2. Proliferation, and apoptosis were observed after different Sa12b concentrations were added to P2 generation NP-MSCs. The Ca²⁺ influx was detected using flow cytometry and laser confocal scanning microscopy, and qPCR was used to detect the relative expression of stem cell–associated genes (Oct4, Nanog, Jag1, and Notch1), the relative expression of extracellular matrix (ECM)–associated genes (collagen II, aggrecan, and SOX-9), and the relative expression of genes encoding ASICs (ASIC1, ASIC2, ASIC3, and ASIC4). Western blotting was used to detect the protein expression of collagen II and aggrecan in different treatment groups. Cells isolated and cultured from normal NP were spindle-shaped and adherent, and they exhibited expansion in vitro. Flow cytometry results showed that the cells exhibited high expression of CD73 (98.1%), CD90 (97.5%), and CD105 (98.3%) and low expression of HLA-DR (0.93%), CD34 (2.63%), and CD45 (0.33%). The cells differentiated into osteoblasts, adipocytes, and chondrocytes. According to the International Society for Cellular Therapy criteria, the isolated and cultured cells were NP-MSCs. With an increase in Sa12b concentration, the cell proliferation rate of NP-MSCs increased, and the apoptosis rate decreased significantly, reaching the optimal level when the concentration of Sa12b was 8 μg/μl. When the Sa12b concentration was 8 μg/μl and contained the ASIC non-specific inhibitor amiloride, the Ca²⁺ influx was the lowest, followed by that when the Sa12b concentration was 8 μg/μl. The Ca²⁺ influx was the highest in the untreated control group. qPCR results showed that as the concentration of Sa12b increased, the relative expression of Oct4, Nanog, Jag1, Notch1, collagen II, aggrecan, and SOX-9 increased, while that of ASIC1, ASIC2, ASIC3, and ASIC4 decreased. The difference was statistically significant (p < 0.05). In conclusion, Sa12b can improve the biological activity of NP-MSCs in severely acidic environments of the intervertebral disc by reducing Ca²⁺ influx via AISC inhibition and, probably, the Notch signaling pathway. This study provides a new approach for the biological treatment of IVDD. Inhibition of AISCs by Sa12b may delay IVDD and improve low back pain.

Misconceptions of physical therapists and medical doctors regarding the impact of lifting a light load on low back pain

BACKGROUND

A common misconception about low back pain (LBP) is that the spine is weak and that lumbar flexion should be avoided. Because the beliefs of health-care professionals (HCPs) influence patients, it is important to understand the attitudes of health care professionals towards LBP and lifting.

OBJECTIVES

To assess and compare the perceptions of different categories of HCPs regarding the safety of specific movement strategies used to lift a light load, and their beliefs regarding back pain. The secondary aim was to determine whether certain factors influenced the beliefs of HCPs.

METHODS

Data were collected via an electronic survey. Student and qualified physical therapists (PTs), medical students, and general practitioner (GP) trainees were included. The questionnaire included eight photographs, depicting eight different strategies to lift a light load. Respondents were requested to select the strategy(s) they considered as "unsafe" to use for asymptomatic people with a previous history of LBP and people with chronic LBP. Beliefs and attitudes towards LBP were evaluated using the Back Pain Attitudes Questionnaire (Back-PAQ).

RESULTS

Questionnaires from 1005 participants were included. Seventy percent of qualified PTs considered none of the strategies as harmful (versus 32% of PT students, 9% of GP trainees and 1% of medical students). Qualified PTs had higher Back-PAQ scores (mean ± SD: 13.6 ± 5.5) than PT students (8.7 ± 5.7), GP trainees (5.9 ± 5.9) and medical students (4.1 ± 5.2), indicating less misconceptions regarding LBP. Having LBP negatively influenced beliefs while taking a pain education course positively influenced beliefs.

CONCLUSION

Misconceptions regarding LBP and the harmfulness of lifting a light load with a rounded back remain common among HCPs, particularly medical doctors.

LOW BACK AND NECK PAIN IN PHYSICAL EDUCATION STUDENTS: PREVALENCE AND ASSOCIATED FACTORS

ABSTRACT Objective: To analyze the prevalence of low back and neck pain in Physical Education (PE) students at the Universidade Federal do Rio Grande do Sul (UFRGS) and the associated behavioral and postural factors. Methods: The study design is observational with descriptive analytics. Healthy PE students of both sexes participated in the study and answered the Back Pain and Body Postural Evaluation Instrument for Adults. Data were analyzed using SPSS software (21.0) using descriptive statistics, calculating the prevalence ratios and 95% confidence intervals. The significance level adopted was 0.05. Results: Ninety-two PE students answered the questionnaire, 45 of whom were females (48.9%) and 47 of whom were males (51.1%). The prevalence of low back pain was 76.1% and of neck pain was 58.7%. There was no association with most of the behavioral and postural factors assessed. Conclusions: The prevalence of low back and neck pain in PE students at UFRGS is high and this pain is not associated with the factors investigated. Level of Evidence II: Prospective study of less quality.

Several low back pain-related misbeliefs are still around in 2020: A cross-sectional survey in Belgium

BACKGROUND AND PURPOSE

Low back pain (LBP)-related misbeliefs are known to be among risk factors for LBP chronification and for persistence of chronic pain. The main objective of this study was to investigate the current LBP-related beliefs in the general population in Belgium, considering the fact that the last survey in Belgium about the topic was conducted more than 15 years ago.

METHODS

A cross-sectional study design was used. Belgian adults (>17 years old) were recruited in the three regions of the country by means of non-probabilistic recruitment methods. Participants were invited to fill in a battery of questionnaires including demographic questions as well as questions about their LBP history and the LBP Beliefs Questionnaire (LBPBQ).

RESULTS

A total of 3724 individuals participated in the study. The LBPBQ scores indicated several LBP-related misbeliefs. About 15%-25% of participants still think that imaging tests can always identify the cause of pain and that bed rest is the mainstay of therapy. The majority of the participants think that "unnecessary" movements should be avoided when having LBP (58% of the respondents), and that they should "take it easy" until the pain goes away (69%). Most respondents also had maladaptive/wrong expectations, for example, a systematic worsening with time (65%) and a need for surgery in case of disc herniation (54%).

CONCLUSIONS

The present study suggests that in 2020 several LBP-related misbeliefs are still current in Belgium, particularly regarding the vulnerability of the spine. Therefore, further efforts to improve LBP-related beliefs/knowledge in the general population are necessary.

Do “Myths” of low back pain exist among young Indian college-going adults with a history of low back pain? A cross-sectional study

Background

Low back pain (LBP) is a prominent public health problem which causes disability around the globe. The prevalence of LBP is on the rise in lower to middle-income countries. India has a varied prevalence of LBP among the rural as well as urban population ranging from 6.2 to 92%. There has been a marked increase in young adults getting LBP with a proportion converting to chronic LBP later in life. Beliefs associated with any disorder affect the course, management, and need for imaging studies. Negative beliefs about LBP in any population may lead to unnecessary psychologic distress and an increase in disease burden. Focusing these negative beliefs on the younger population can help curb the chronicity and lessen the disability caused by it. This cross-sectional study explored the presence of myths in 516 college-going Indian young adults from Lovely Professional University.

Results

A total of 516 individuals participated in the study. The mean (SD) age of the participants was 22.69 years (2.417). Among them, 47.5% (245) were females and 52.5% (271) were males. The findings show that a high percentage of college-going young adults have false beliefs in most of the ten domains (myths) explored. The most prevalent myths were “LBP is caused by weak ‘core’ muscles and having a strong core protects against future LBP” (81.2%) and “LBP is caused by poor posture when sitting, standing, and lifting” with 80.6% agreeing to it.

Conclusion

Our study demonstrated that the myths of low back pain are widespread among the studied population. The findings suggest that community education programs must be developed to address these myths, hence reducing the disease burden associated with back pain.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

Self-management at the core of back pain care: 10 key points for clinicians

BACKGROUND

A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

OBJECTIVE

In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

DISCUSSION

People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

Physiotherapists' attitudes and beliefs about low back pain influence their clinical decisions and advice

BACKGROUND

Physiotherapists' biomedical orientation influences the implementation of evidenced-based care for low back pain (LBP) management. However, information on physiotherapists' own beliefs about their back and LBP and the influence of these on clinical decisions and advice is lacking.

OBJECTIVES

To identify attitudes and beliefs about LBP among physiotherapists and to analyse the association of these beliefs with physiotherapists' individual characteristics and clinical decisions and advice.

DESIGN

Cross-sectional survey.

METHOD

Attitudes and beliefs about LBP were measured with the Back-Pain Attitudes Questionnaire (Back-PAQ) among French-speaking Swiss physiotherapists. Physiotherapists' clinical decisions and advice were assessed with a clinical vignette to determine their association with the Back-PAQ score.

RESULTS

The study included 288 physiotherapists. The mean Back-PAQ score (82.7; SD 17.2) indicated the presence of helpful beliefs in general, but unhelpful beliefs in relation to back protection and the special nature of LBP (nature of pain, impact, complexity) were frequently identified. Individual characteristics explained 17% of the Back-PAQ score. Unhelpful beliefs were associated with clinical decisions toward back protection and movement avoidance (r = - 0.47, p < 0.001).

CONCLUSIONS

While helpful beliefs and guidelines consistent decisions were generally identified, unhelpful beliefs about back protection and the special nature of LBP were frequently present among physiotherapists. These unhelpful beliefs were associated with less optimal clinical decisions. Educational approaches should challenge unhelpful beliefs and empower physiotherapists to provide explanations and management that increases patients' confidence in the back. Future research should investigate the effect of educational strategies on implementation of best practice for LBP management.

A Cognitive Functional Therapy+ Pathway Versus an Interdisciplinary Pain Management Pathway for Patients With Severe Chronic Low Back Pain (CONFeTTI Trial): Protocol for a Pragmatic Randomized Controlled Trial

OBJECTIVE

Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care).

METHODS

This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D.

IMPACT

The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.

Brief action planning targeting prognostic factors for an adult with persistent low back pain without radiculopathy: A case report

We describe the implementation of brief action planning in conjunction with evidence-based clinical practice guideline recommendations to improve self-efficacy in a patient with psychosocial barriers and persistent nonspecific low back pain.

Beliefs about the body and pain: the critical role in musculoskeletal pain management

BACKGROUND

Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by pain. Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability. Clinical guidelines recommend addressing unhelpful beliefs as the first line of treatment in all patients presenting with musculoskeletal pain. However, many clinicians hold unhelpful beliefs themselves; while others feel ill-equipped to explore and target the beliefs driving unhelpful responses to pain. As a result, clinicians may reinforce unhelpful beliefs, behaviours and resultant disability among the patients they treat.

METHODS

To assist clinicians, in Part 1 of this paper we discuss what beliefs are; how they are formed; the impact they can have on a person's behaviour, emotional responses and outcomes of musculoskeletal pain. In Part 2, we discuss how we can address beliefs in clinical practice. A clinical case is used to illustrate the critical role that beliefs can have on a person's journey from pain and disability to recovery.

CONCLUSIONS

We encourage clinicians to exercise self-reflection to explore their own beliefs and better understand their biases, which may influence their management of patients with musculoskeletal pain. We suggest actions that may benefit their practice, and we propose key principles to guide a process of behavioural change.