Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey

Preliminary Validity and Acceptability of Motion Tape for Measuring Low Back Movement: Mixed Methods Study

BACKGROUND

Low back pain (LBP) is a significant public health problem that can result in physical disability and financial burden for the individual and society. Physical therapy is effective for managing LBP and includes evaluation of posture and movement, interventions directed at modifying posture and movement, and prescription of exercises. However, physical therapists have limited tools for objective evaluation of low back posture and movement and monitoring of exercises, and this evaluation is limited to the time frame of a clinical encounter. There is a need for a valid tool that can be used to evaluate low back posture and movement and monitor exercises outside the clinic. To address this need, a fabric-based, wearable sensor, Motion Tape (MT), was developed and adapted for a low back use case. MT is a low-profile, disposable, self-adhesive, skin-strain sensor developed by spray coating piezoresistive graphene nanocomposites directly onto commercial kinesiology tape.

OBJECTIVE

The objectives of this study were to (1) validate MT for measuring low back posture and movement and (2) assess the acceptability of MT for users.

METHODS

A total of 10 participants without LBP were tested. A 3D optical motion capture system was used as a reference standard to measure low back kinematics. Retroreflective markers and a matrix of MTs were placed on the low back to measure kinematics (motion capture) and strain (MT) simultaneously during low back movements in the sagittal, frontal, and axial planes. Cross-correlation coefficients were calculated to evaluate the concurrent validity of MT strain in reference motion capture kinematics during each movement. The acceptability of MT was assessed using semistructured interviews conducted with each participant after laboratory testing. Interview data were analyzed using rapid qualitative analysis to identify themes and subthemes of user acceptability.

RESULTS

Visual inspection of concurrent MT strain and kinematics of the low back indicated that MT can distinguish between different movement directions. Cross-correlation coefficients between MT strain and motion capture kinematics ranged from -0.915 to 0.983, and the strength of the correlations varied across MT placements and low back movement directions. Regarding user acceptability, participants expressed enthusiasm toward MT and believed that it would be helpful for remote interventions for LBP but provided suggestions for improvement.

CONCLUSIONS

MT was able to distinguish between different low back movements, and most MTs demonstrated moderate to high correlation with motion capture kinematics. This preliminary laboratory validation of MT provides a basis for future device improvements, which will also involve testing in a free-living environment. Overall, users found MT acceptable for use in physical therapy for managing LBP.

Quantifying lumbar mobility using a single tri-axial accelerometer

Background

Lumbar mobility is regarded as important for assessing and managing low back pain (LBP). Inertial Measurement Units (IMUs) are currently the most feasible technology for quantifying lumbar mobility in clinical and research settings. However, their gyroscopes are susceptible to drift errors, limiting their use for long-term remote monitoring.

Research question

Can a single tri-axial accelerometer provide an accurate and feasible alternative to a multi-sensor IMU for quantifying lumbar flexion mobility and velocity?

Methods

In this cross-sectional study, 18 healthy adults performed nine repetitions of full spinal flexion movements. Lumbar flexion mobility and velocity were quantified using a multi-sensor IMU and just the tri-axial accelerometer within the IMU. Correlations between the two methods were assessed for each percentile of the lumbar flexion movement cycle, and differences in measurements were modelled using a Generalised Additive Model (GAM).

Results

Very high correlations (r > 0.90) in flexion angles and velocities were found between the two methods for most of the movement cycle. However, the accelerometer overestimated lumbar flexion angle at the start (-4.7° [95 % CI -7.6° to -1.8°]) and end (-4.8° [95 % CI -7.7° to -1.9°]) of movement cycles, but underestimated angles (maximal difference of 4.3° [95 % CI 1.4° to 7.2°]) between 7 % and 92 % of the movement cycle. For flexion velocity, the accelerometer underestimated at the start (16.6°/s [95%CI 16.0 to 17.2°/s]) and overestimated (-12.3°/s [95%CI -12.9 to -11.7°/s]) at the end of the movement, compared to the IMU.

Significance

Despite the observed differences, the study suggests that a single tri-axial accelerometer could be a feasible tool for continuous remote monitoring of lumbar mobility and velocity. This finding has potential implications for the management of LBP, enabling more accessible and cost-effective monitoring of lumbar mobility in both clinical and research settings.

Quantifying lumbar sagittal plane kinematics using a wrist-worn inertial measurement unit

Wearable sensors like inertial measurement units (IMUs), and those available as smartphone or smartwatch applications, are increasingly used to quantify lumbar mobility. Currently, wearable sensors have to be placed on the back to measure lumbar mobility, meaning it cannot be used in unsupervised environments. This study aims to compare lumbar sagittal plane angles quantified from a wrist-worn against that of a lumbar-worn sensor. Twenty healthy participants were recruited. An IMU was placed on the right wrist and the L3 spinal level. Participants had to position their right forearm on their abdomen, parallel to the floor. Three sets of three consecutive repetitions of flexion, and extension were formed. Linear mixed models were performed to quantify the effect of region (lumbar vs. wrist) on six outcomes [minimum, maximum, range of motion (ROM) of flexion and extension]. Only flexion ROM was significantly different between the wrist and lumbar sensors, with a mean of 4.54° (95% CI = 1.82°-7.27°). Across all outcomes, the maximal difference between a wrist-worn and lumbar-worn sensor was <8°. A wrist-worn IMU sensor could be used to measure gross lumbar sagittal plane mobility in place of a lumbar-worn IMU. This may be useful for remote monitoring during rehabilitation.

Physical Therapists' Acceptance of a Wearable, Fabric-Based Sensor System (Motion Tape) for Use in Clinical Practice: Qualitative Focus Group Study

BACKGROUND

Low back pain (LBP) is a costly global health condition that affects individuals of all ages and genders. Physical therapy (PT) is a commonly used and effective intervention for the management of LBP and incorporates movement assessment and therapeutic exercise. A newly developed wearable, fabric-based sensor system, Motion Tape, uses novel sensing and data modeling to measure lumbar spine movements unobtrusively and thus offers potential benefits when used in conjunction with PT. However, physical therapists' acceptance of Motion Tape remains unexplored.

OBJECTIVE

The primary aim of this research study was to evaluate physical therapists' acceptance of Motion Tape to be used for the management of LBP. The secondary aim was to explore physical therapists' recommendations for future device development.

METHODS

Licensed physical therapists from the American Physical Therapy Association Academy of Leadership Technology Special Interest Group participated in this study. Overall, 2 focus groups (FGs; N=8) were conducted, in which participants were presented with Motion Tape samples and examples of app data output on a poster. Informed by the Technology Acceptance Model, we conducted semistructured FGs and explored the wearability, usefulness, and ease of use of and suggestions for improvements in Motion Tape for PT management of LBP. FG data were transcribed and analyzed using rapid qualitative analysis.

RESULTS

Regarding wearability, participants perceived that Motion Tape would be able to adhere for several days, with some variability owing to external factors. Feedback was positive for the low-profile and universal fit, but discomfort owing to wires and potential friction with clothing was of concern. Other concerns included difficulty with self-application and potential skin sensitivity. Regarding usefulness, participants expressed that Motion Tape would enhance the efficiency and specificity of assessments and treatment. Regarding ease of use, participants stated that the app would be easy, but data management and challenges with interpretation were of concern. Physical therapists provided several recommendations for future design improvements including having a wireless system or removable wires, customizable sizes for the tape, and output including range of motion data and summary graphs and adding app features that consider patient input and context.

CONCLUSIONS

Several themes related to Motion Tape's wearability, usefulness, and ease of use were identified. Overall, physical therapists expressed acceptance of Motion Tape's potential for assessing and monitoring low back posture and movement, both within and outside clinical settings. Participants expressed that Motion Tape would be a valuable tool for the personalized treatment of LBP but highlighted several future improvements needed for Motion Tape to be used in practice.

Long-term effects of lumbar flexion versus extension exercises for chronic axial low back pain: a randomized controlled trial

This study aimed to compare the long-term effects of flexion- and extension-based lumbar exercises on chronic axial low back pain (LBP). This was a 1-year follow-up of a prospective, assessor-blind, randomized controlled trial. Patients with axial LBP (intensity ≥ 5/10) for > 6 months allocated to the flexion or extension exercise group. Patients underwent four sessions of a supervised treatment program and were required to perform their assigned exercises daily at home. Clinical outcomes were obtained at baseline, 1, 3, 6 months, and 1-year. A total of 56 patients (age, 54.3 years) were included, with 27 and 29 in the flexion and extension groups, respectively. Baseline pain and functional scales were similar between both groups. The mean (± standard deviation) baseline average back pain was 6.00 ± 1.00 and 5.83 ± 1.20 in the flexion and extension groups, respectively. At 1-year, the average pain was 3.78 ± 1.40 and 2.26 ± 2.62 (mean between-group difference, 1.52; 95% confidence interval 0.56-2.47; p = 0.002), favoring extension exercise. The extension group tended to have more improvements in current pain, least pain, and pain interference than the flexion group at 1-year. However, there was no group difference in worst pain and functional scales. In this controlled trial involving patients with chronic axial LBP, extension-based lumbar exercise was more effective in reducing pain than flexion-based exercises at 1-year, advocating lumbar extension movement pattern as a component for therapeutic exercise for chronic LBP.Clinical Trial Registration No.: NCT02938689 (Registered on www.clinicaltrial.gov ; first registration date was 19/10/2016).

The Use of Cluster Analysis by Partitioning around Medoids (PAM) to Examine the Heterogeneity of Patients with Low Back Pain within Subgroups of the Treatment Based Classification System

Background

Current evidence in low back pain (LBP) focuses on population averages and traditional multivariate analyses to find the significant difference between variables. Such a focus actively obscured the heterogeneity and increased errors. Cluster analysis (CA) addresses the mentioned shortcomings by calculating the degree of similarity among the relevant variables of the different objects.

Objective

This study aims to evaluate the agreement between the treatment-based classification (TBC) system and the equivalent 3 cluster typology created by partitioning around medoids (PAM) analysis.

Material and Methods

In this cross-sectional study, a convenient sample of 90 patients with low back pain (50 males and 40 females) aged 20 to 65 years was included in the study. The patients were selected based on the 21 criteria of 2007 TBC system. An equivalent 3 cluster typology (C3) was applied using PAM method. Cohen's Kappa was run to determine if there was agreement between the TBC system and the equivalent C3 typology.

Results

PAM analysis revealed the evidence of clustering for a C3 cluster typology with average Silhouette widths of 0.12. Cohen's Kappa revealed fair agreement between the TBC system and C3 cluster typology (Percent of agreement 61%, Kappa=0.36, P<0.001). Selected criteria by PAM analysis were different with original TBC system.

Conclusion

Higher probability of chance agreement was observed between two classification methods. Significant inhomogeneity was observed in subgroups of the 2007 TBC system.

Extraction of Lumbar Spine Motion Using a 3-IMU Wearable Cluster

Spine movement is a daily activity that can indicate health status changes, including low back pain (LBP) problems. Repetitious and continuous movement on the spine and incorrect postures during daily functional activities may lead to the potential development and persistence of LBP problems. Therefore, monitoring of posture and movement is essential when designing LBP interventions. Typically, LBP diagnosis is facilitated by monitoring upper body posture and movement impairments, particularly during functional activities using body motion sensors. This study presents a fully wireless multi-sensor cluster system to monitor spine movements. The study suggests an attempt to develop a new method to monitor the lumbopelvic movements of interest selectively. In addition, the research employs a custom-designed robotic lumbar spine simulator to generate the ideal lumbopelvic posture and movements for reference sensor data. The mechanical motion templates provide an automated sensor pattern recognition mechanism for diagnosing the LBP.

Back pain treatment: a new perspective

This article aims to provide new perspectives for the treatment of low back pain (LBP). A narrative literature review highlights the treatment strategies currently anchored in the guidelines as well as the extensive attempts to identify subgroups within the non-specific low back pain (NSLBP) classification. A variety of multimodal approaches exist for both diagnostic assessments and therapy approaches. Nonetheless, there are often gaps in the classification systems as well as in published treatment concepts with regard to the implementation of musculoskeletal functional disorders. Indeed, a growing body of evidence shows that more holistic and flexible approaches are needed to individually diagnose and target the complexity of LBP. As an example, both a diagnostic and a (independently developed) therapeutic LBP concept will be presented and discussed. Ultimately, guidelines and subgroup classification systems can only reflect the complexity of LBP, if they capture its entire multidimensional and biopsychosocial character in both the diagnostic and therapeutic processes. Furthermore, the expansion of the pain definition to include the nociplastic pain mechanism, as an important driver of LBP, has the potential to provide important impulses for further necessary research. In conclusion, the implementation of a functional musculoskeletal approach along with the emerging nociceptive pain concept in individually targeted holistic approaches seems to be the successful way to deal with the complexity of LBP.

Developmental Dyslexia: Disorder or Specialization in Exploration?

We raise the new possibility that people diagnosed with developmental dyslexia (DD) are specialized in explorative cognitive search, and rather than having a neurocognitive disorder, play an essential role in human adaptation. Most DD research has studied educational difficulties, with theories framing differences in neurocognitive processes as deficits. However, people with DD are also often proposed to have certain strengths - particularly in realms like discovery, invention, and creativity - that deficit-centered theories cannot explain. We investigate whether these strengths reflect an underlying explorative specialization. We re-examine experimental studies in psychology and neuroscience using the framework of cognitive search, whereby many psychological processes involve a trade-off between exploration and exploitation. We report evidence of an explorative bias in DD-associated cognitive strategies. High DD prevalence and an attendant explorative bias across multiple areas of cognition suggest the existence of explorative specialization. An evolutionary perspective explains the combination of findings and challenges the view that individuals with DD have a disorder. In cooperating groups, individual specialization is favored when features that confer fitness benefits are functionally incompatible. Evidence for search specialization suggests that, as with some other social organisms, humans mediate the exploration-exploitation trade-off by specializing in complementary strategies. The existence of a system of collective cognitive search that emerges through collaboration would help to explain our species' exceptional adaptiveness. It also aligns with evidence for substantial variability during our evolutionary history and the notion that humans are adapted not to a particular habitat but to variability itself. Specialization creates interdependence and necessitates balancing complementary strategies. Reframing DD therefore underscores the urgency of changing certain cultural practices to ensure we do not inhibit adaptation. Key improvements would remove cultural barriers to exploration and nurture explorative learning in education, academia, and the workplace, as well as emphasize collaboration over competition. Specialization in complementary search abilities represents a meta-adaptation; through collaboration, this likely enables human groups (as a species and as cultural systems) to successfully adapt. Cultural change to support this system of collaborative search may therefore be essential in confronting the challenges humanity now faces.

Development and content validity of a rating scale for the pain and disability drivers management model

Background

Establishing the biopsychosocial profile of patients with low back pain (LBP) is essential to personalized care. The Pain and Disability Drivers Management model (PDDM) has been suggested as a useful framework to help clinicians establish this biopsychosocial profile. Yet, there is no tool to facilitate its integration into clinical practice. Thus, the aim of this study is to develop a rating scale and validate its content, to rapidly establish the patient’s biopsychosocial profile, based on the five domains of the PDDM.

Methods

The tool was developed in accordance with the principles of the COSMIN methodology. We conducted three steps: 1) item generation from a comprehensive review, 2) refinement of the scale with clinicians’ feedback, and 3) statistical analyses to assess content validity.

To validate the item assessing with Likert scales, we performed Item level-Content Validity Index (I-CVI) analyses on three criteria (clarity, presentation and clinical applicability) with an a priori threshold of > 0.78. We conducted Average-Content Validity Index (Ave-CVI) analyses to validate the overall scale with a threshold of > 0.9.

Results

In accordance with the PDDM, we developed a 5-item rating scale (1 per domain) with 4 score options. We selected clinical instruments to screen for the presence or absence of problematic issues within each category of the 5 domains. Forty-two participants provided feedback to refine the scale’s clarity, presentation, and clinical applicability. The statistical analysis of the latest version presented I-CVI above the threshold for each item (I-CVI ranged between 0.94 and 1). Analysis of the overall scale supported its validation (Ave-CVI = 0.96 [0.93;0.98]).

Conclusion

From the 51 biopsychosocial elements contained within the 5 domains of the PDDM, we developed a rating scale that allows to rapidly screen for problematic issues within each category of the PDDM’s 5 domains. Involving clinicians in the process allowed us to validate the content of the first scale to establish the patient’s biopsychosocial profile for people with low back pain. Future steps will be necessary to continue the psychometric properties analysis of this rating scale.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-022-00137-2.

Coordination Between Trunk Muscles, Thoracolumbar Fascia, and Intra-Abdominal Pressure Toward Static Spine Stability

STUDY DESIGN

Numerical in-silico human spine stability finite element analysis.

OBJECTIVE

The purpose of this study was to investigate the contribution of major torso tissues toward static spine stability, mainly the thoracolumbar fascia (TLF), abdominal wall with its intra-abdominal pressure (IAP), and spinal muscles inclusive of their intramuscular pressure.

SUMMARY OF BACKGROUND DATA

Given the numerous redundancies involved in the spine, current methodologies for assessing static spinal stability are limited to specific tissues and could lead to inconclusive results. A three-dimensional finite element model of the spine, with structured analysis of major torso tissues, allows for objective investigation of static spine stability.

METHODS

A novel previously fully validated spine model was employed. Major torso tissues, mainly the muscles, TLF, and IAP were individually, and in combinations, activated under a 350N external spine perturbation. The stability contribution exerted by these tissues, or their ability to restore the spine to the unperturbed position, was assessed in different case-scenarios.

RESULTS

Individual activations recorded significantly different stability contributions, with the highest being the TLF at 75%. Combined or synergistic activations showed an increase of up to 93% stability contribution when all tissues were simultaneously activated with a corresponding decrease in the tensile load exerted by the tissues themselves.

CONCLUSION

This investigation demonstrated torso tissues exhibiting different roles toward static spine stability. The TLF appeared able to dissipate and absorb excessive loads, the muscles acted as antagonistic to external perturbations, and the IAP played a role limiting movement. Furthermore, the different combinations explored suggested an optimized engagement and coordination between different tissues to achieve a specific task, while minimizing individual work.Level of Evidence: N/A.

A vision for the future of wearable sensors in spine care and its challenges: narrative review

OBJECTIVE

This review aimed to: (I) provide a brief overview of some topical areas of current literature regarding applications of wearable sensors in the management of low back pain (LBP); (II) present a vision for a future comprehensive system that integrates wearable sensors to measure multiple parameters in the real world that contributes data to guide treatment selection (aided by artificial intelligence), uses wearables to aid treatment support, adherence and outcome monitoring, and interrogates the response of the individual patient to the prescribed treatment to guide future decision support for other individuals who present with LBP; and (III) consider the challenges that will need to be overcome to make such a system a reality.

BACKGROUND

Advances in wearable sensor technologies are opening new opportunities for the assessment and management of spinal conditions. Although evidence of improvements in outcomes for individuals with LBP from the use of sensors is limited, there is enormous future potential.

METHODS

Narrative review and literature synthesis.

CONCLUSIONS

Substantial research is underway by groups internationally to develop and test elements of this system, to design innovative new sensors that enable recording of new data in new ways, and to fuse data from multiple sources to provide rich information about an individual's experience of LBP. Together this system, incorporating data from wearable sensors has potential to personalise care in ways that were hitherto thought impossible. The potential is high but will require concerted effort to develop and ultimately will need to be feasible and more effective than existing management.

Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis

OBJECTIVE

To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP).

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened.

STUDY SELECTION CRITERIA

We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded.

DATA SYNTHESIS

Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration.

RESULTS

Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful.

CONCLUSION

For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

Recovery of the lumbopelvic movement and muscle recruitment patterns using motor control exercise program in people with chronic nonspecific low back pain: A prospective study

This study aims to investigate the dysfunction and recovery of the lumbopelvic movement and motor control of people with chronic nonspecific low back pain after a structured rehabilitation which emphasizes on re-education and training of movement and motor control. The lumbopelvic movement and motor control pattern of 30 adults (15 with chronic low back pain, 15 healthy controls) were assessed using 3D motion and electromyographic analysis during the repeated forward bending test, in additional to the clinical outcome measures. Regional kinematics and muscle recruitment pattern of the symptomatic group was analysed before and after the 6-week rehabilitation, and compared to healthy controls. Significant improvement in back pain, functional capacity and self-efficacy of the symptomatic group was found after the rehabilitation. Patients with chronic nonspecific low back pain were capable to recover to a comparable level of the healthy controls in terms of their lumbopelvic movement and motor control pattern upon completion of a 6-week rehabilitation program, despite their dysfunction displayed at baseline. Phase specific motor control reorganization in which more profound and positive changes shown during the flexion phase. Our findings indicate that the recovery of the movement and motor control pattern in patients with chronic low back pain achieved to a comparable level of the healthy able-bodies. The improvement of both the physical outcome measures suggest that specific rehabilitation program which emphasizes on optimizing motor control during movements would help promoting the functional recovery of this specific low back pain subgroup.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

Effects of behavioural exercise therapy on the effectiveness of multidisciplinary rehabilitation for chronic non-specific low back pain: a randomised controlled trial

BACKGROUND

The long-term effects of behavioural medical rehabilitation (BMR), as a type of multidisciplinary rehabilitation, in the treatment of chronic non-specific low back pain (CLBP) have been shown. However, the specific effects of behavioural exercise therapy (BET) compared to standard exercise therapy (SET) within BMR are not well understood. The aim of the study was to assess the effectiveness of BMR + BET compared to BMR + SET in individuals with CLBP in a two-armed, pre-registered, multicentre, parallel, randomised controlled trial (RCT).

METHODS

A total of 351 adults with CLBP in two rehabilitation centres were online randomised based on an 'urn randomisation' algorithm to either BMR + SET (n = 175) or BMR + BET (n = 176). Participants in both study groups were non-blinded and received BMR, consisting of an multidisciplinary admission, a psychosocial assessment, multidisciplinary case management, psychological treatment, health education and social counselling. The intervention group (BMR + BET) received a manualised, biopsychosocial BET within BMR. The aim of BET was to develop self-management strategies in coping with CLBP. The control group (BMR + SET) received biomedical SET within BMR with the aim to improve mainly physical fitness. Therapists in both study groups were not blinded. The BMR lasted on average 27 days, and both exercise programmes had a mean duration of 26 h. The primary outcome was functional ability at 12 months. Secondary outcomes were e.g. pain, avoidance-endurance, pain management and physical activity. The analysis was by intention-to-treat, blinded to the study group, and used a linear mixed model.

RESULTS

There were no between-group differences observed in function at the end of the BMR (mean difference, 0.08; 95% CI - 2.82 to 2.99; p = 0.955), at 6 months (mean difference, - 1.80; 95% CI; - 5.57 to 1.97; p = 0.349) and at 12 months (mean difference, - 1.33; 95% CI - 5.57 to 2.92; p = 0.540). Both study groups improved in the primary outcome and most secondary outcomes at 12 months with small to medium effect sizes.

CONCLUSION

BMR + BET was not more effective in improving function and other secondary outcomes in individuals with CLBP compared to BMR + SET.

TRIAL REGISTRATION

Current controlled trials NCT01666639 , 16/08/2012.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation

BACKGROUND

Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs.

OBJECTIVES

The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice.

METHODS

We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process.

RESULTS

We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP.

CONCLUSIONS

We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

ICD-10 Coding of Musculoskeletal Conditions in the Veterans Health Administration

OBJECTIVE

We describe the most frequently used musculoskeletal diagnoses in Veterans Health Administration (VHA) care. We report the number of visits and patients associated with common musculoskeletal ICD-10 codes and compare trends across primary and specialty care settings.

DESIGN

Secondary analysis of a longitudinal cohort study.

SUBJECTS

Veterans included in the Musculoskeletal Diagnosis Cohort with a musculoskeletal diagnosis from October 1, 2015 through September 30, 2017.

METHODS

We obtained counts and proportions of all musculoskeletal diagnosis codes used and the number of unique patients with each musculoskeletal diagnosis. Diagnosis use was compared between primary and specialty care settings.

RESULTS

Of over 6,400 possible ICD-10 M-codes describing "Diseases of the Musculoskeletal System and Connective Tissue", 5,723 codes were used at least once. The most frequently used ICD-10 M-code was "Low Back Pain" (18.3%) followed by "Cervicalgia" (3.6%). Collectively, the 100 most frequently used codes accounted for 80% of M-coded visit diagnoses, and 95% of patients had at least one of these diagnoses. The most common diagnoses (spinal pain, joint pain, osteoarthritis) were used similarly in primary and specialty care settings.

CONCLUSION

A diverse sample of all available musculoskeletal diagnosis codes were used; however, less than 2% of all possible codes accounted for 80% of the diagnoses used. This trend was consistent across primary and specialty care settings. The most frequently used diagnosis codes describe the types of musculoskeletal conditions, among a large pool of potential diagnoses, that prompt veterans to present to VHA for musculoskeletal care.

Optimizing management of low back pain through the pain and disability drivers management model: A feasibility trial

INTRODUCTION

Self-reported levels of disability in individuals with low back pain (LBP) have not improved in the last decade. A broader perspective and a more comprehensive management framework may improve disability outcomes. We recently developed and validated the Low Back Pain and Disability Drivers Management (PDDM) model, which aims to identify the domains driving pain and disability to guide clinical decisions. The objectives of this study were to determine the applicability of the PDDM model to a LBP population and the feasibility of conducting a pragmatic trial, as well as to explore clinicians' perceived acceptability of the PDDM model's use in clinical settings.

METHODS

This study was an one-arm prospective feasibility trial. Participants included physiotherapists working with a population suffering from LBP and their patients aged 18 years or older presenting with a primary complaint of LBP that sought a new referral and deemed fit for rehabilitation from private and public clinical settings. Clinicians participated in a one-day workshop on the integration of the PDDM model into their clinical practice, and were asked to report various LBP-related outcomes via self-reported questionnaires (i.e., impact of pain on physical function, nervous system dysfunctions, cognitive-emotional factors, work disabilities) at baseline and at six-week follow-up. Physiotherapists' acceptability of the use of the PDDM model and appreciation of the training were assessed via semi-structured phone interviews. Analyses focused on a description of the model's applicability to a LBP population, feasibility outcomes and acceptability measures.

RESULTS

Applicablity of the PDDM model was confirmed since it successfully established the profile of patients according to the elements of each categories, and each of the 5 domains of the model was represented among the study sample. Trial was deemed feasible contingent upon few modifications as our predefined success criteria for the feasibility outcomes were met but feasibility issues pertaining to data collection were highlighted. Twenty-four (24) clinicians and 61 patients were recruited within the study's timeframe. Patient's attrition rate (29%) and clinicians' compliance to the study protocol were adequate. Clinicians' perceived acceptability of the use of the model in clinical settings and their appreciation of the training and online resources were both positive. Recommendations to improve the model's integration in clinical practice, content of the workshop and feasibility of data collection methods were identified for future studies. A positive effect for all patients' reported outcome measures were also observed. All outcome measures except for the PainDetect questionnaire showed a statistically significant reduction post-intervention (p<0.05).

CONCLUSION

These findings provide preliminary evidence of the potential of the PDDM model to optimize LBP management as well as conducting a future larger-scale pragmatic trial to determine its effectiveness.

TRIAL REGISTRATION

Clinicaltrial.gov: NCT03949179.

A New Clustering Method for Knee Movement Impairments using Partitioning Around Medoids Model

Background:

The movement system impairment (MSI) model is a clinical model that can be used for the classification, diagnosis, and treatment of knee impairments. By using the partitioning around medoids (PAM) clustering method, patients can be easily clustered in homogeneous groups through the determination of the most discriminative variables. The present study aimed to reduce the number of clinical examination variables, determine the important variables, and simplify the MSI model using the PAM clustering method.

Methods:

The present cross-sectional study was performed in Shiraz, Iran, during February-December 2018. A total of 209 patients with knee pain were recruited. Patients’ knee, femoral and tibial movement impairments, and the perceived pain level were examined in quiet standing, sitting, walking, partial squatting, single-leg stance (both sides), sit-to-stand transfer, and stair ambulation. The tests were repeated after correction for impairments. Both the pain pattern and the types of impairment were subsequently used in the PAM clustering analysis.

Results:

PAM clustering analysis categorized the patients in two main clusters (valgus and non-valgus) based on the presence or absence of valgus impairment. Secondary analysis of the valgus cluster identified two sub-clusters based on the presence of hypomobility. Analysis of the non-valgus cluster showed four sub-clusters with different characteristics. PAM clustering organized important variables in each analysis and showed that only 23 out of the 41 variables were essential in the sub-clustering of patients with knee pain.

Conclusion:

A new direct knee examination method is introduced for the organization of important discriminative tests, which requires fewer clinical examination variables.

Effects of a movement control and tactile acuity training in patients with nonspecific chronic low back pain and control impairment - a randomised controlled pilot study

Background

Nonspecific chronic low back pain (NSCLBP) is a heterogeneous condition that is associated with complex neuromuscular adaptations. Exercise is a widely administered treatment, but its effects are small to moderate. Tailoring patient-specific exercise treatments based on subgroup classification may improve patient outcomes.

Objective

In this randomised controlled pilot study, our objective was to compare the feasibility and possible effects of a specific sensorimotor treatment (SMT) with those of a general exercise (GE) programme on patients with NSCLBP and control impairment (CI).

Methods

Patients with NSCLBP and CI were randomised into an SMT or a GE programme spanning 6 sessions each. The feasibility criteria included the study design, assessments, interventions and magnitudes of effects, and costs. Adverse events were documented. Primary (pain, physical function, and quality of life) and secondary outcomes were assessed three times: twice at baseline (t1a and t1b) to estimate parameter stability and once after the intervention (t2).

Results

Two-hundred and twenty-seven patients were screened to include 34 participants with NSCLBP and CI. Both treatment programmes and the assessments seemed feasible because their durations and contents were perceived as adequate. The total cost per participant was €321. Two adverse events occurred (one not likely related to the SMT, one likely related to the GE intervention).

The SMT showed a tendency for superior effects in terms of pain severity (SMT t1a 3.5, t2 1.1; GE t1a 3.0, t2 2.0), pain interference (SMT t1a 1.9, t2 0.4; GE t1a 1.5, t2 0.9), physical component of quality of life (SMT t1a 39, t2 46; GE t1a 45, t2 48), and movement control.

Conclusions

The SMT approach proposed in this study is feasible and should be tested thoroughly in future studies, possibly as an addition to GE. To ensure the detection of differences in pain severity between SMT and GE in patients with NSCLBP with 80% power, future studies should include 110 patients. If the current results are confirmed, SMT should be considered in interventions for patients with NSCLBP and CI.

Trial registration

Registered in the German Register for Clinical Trials (Trial registration date: November 11, 2016; Trial registration number: DRKS00011063; URL of trial registry record); retrospectively registered.

Eligibility of the movement-based classification systems in the diagnosis of patients with low back pain: A systematic review

OBJECTIVE

To evaluate the eligibility of the movement-based classification systems in the diagnosis of patients with low back pain.

METHODS

The present systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta -Analysis guidelines. Different databases including PubMed, Science Direct, OVID, MEDLINE, CINAHL, EMBASE, ProQuest and Google Scholar were searched from January 1990 to December 2017. All studies assessed the reliability and validity of the movement-based classification systems to diagnose patients with low back pain were included. The keywords used to search the studies were: "reliability", "validity", "classification", "movement impairment" and "low back pain". Study selection and data extraction were performed by two independent reviewers.

RESULTS

Sixteen articles were met the inclusion criteria. Of these articles, 13 studies assessed the reliability and validity of movement-based classification systems to categorize patients with low back pain. Two out of 16 articles compared patients with low back pain and healthy subjects and one article had no control group.

CONCLUSIONS

The results of the reviewed studies demonstrated that movement-based classification systems are valid and reliable enough to categorize patients with low back pain.

CLASSIFICATION OF LOW BACK PAIN INTO SUBGROUPS FOR DIAGNOSTIC AND THERAPEUTIC CLARITY

ABSTRACT Objective To establish a classification in subgroups with symptoms and functionality involving volunteers with nonspecific chronic low back pain for better clarity of functional and therapeutic diagnostic definitions. Methods Observational, quantitative, cross-sectional study with population of 62 university students between 18 and 30 years of age, with a mean age of 21.40 (± 2.40) years, presenting nonspecific lumbar pain for more than three months. Three questionnaires were used for the division into subgroups: STarT Back Screening, the Oswestry Disability Index, and FABQ-Brasil, the VAS evaluation, orthopedic tests: Lasègue’s, Slump test, de Sèze test, Valsalva maneuver, and evaluation of the pain threshold of the right and left iliocostal lumbar muscles. Results All the volunteers included in the study had chronic back pain. Most of them (50%) had normal body mass index, 54.8% were sedentary, and of those who were physically active, 14.5% did body building. The Slump test (35.5%) proved to be more reliable than Lasègue’s test (21%). In the evaluation, the volunteers reported moderate pain intensity (72.6%) and the mean pressure pain threshold was 6.37 kgf and 6.14 kgf for the right and left iliocostal muscles, respectively. In the questionnaires, 85.5% had a low-risk score, that is, a good prognosis for pain treatment, and 91.9% had minimum disability. The largest treatment hypothesis group was stabilization (29.0%). Conclusion The method of treatment subgroup classification is a guide towards better semiological perspectives and the definition of the clinically preferred physiotherapeutic treatment for each case. Level of Evidence III; Diagnostic study.

The McKenzie Method and its association with psychosocial outcomes in low back pain: a systematic review

Study Design: Systematic Literature Review.Background: The McKenzie Method (MDT) is a comprehensive conservative approach commonly used for the management of low back pain (LBP); however, its association with psychosocial outcomes in this population is less clear.Objectives: Evaluate whether MDT has an association with psychosocial outcomes for individuals with LBP.Methods: The following electronic databases were searched: Medline, Pubmed, Cochrane, CINAHL, Embase and AMED. They were systematically searched from the date of inception to August 2019. Included studies had to have participants experiencing LBP who were over 18 years old, utilize MDT as an assessment or intervention, and report outcomes for at least one psychosocial variable. Three reviewers independently evaluated methodological quality of randomized control trials (RCT) using the PEDro scale and observational studies using the GRACE scale.Results: The initial search resulted in 181 articles to review. After screening abstracts, then full articles, a total of 16 studies were included, 5 of which were RCTs rated 5-8/10 on the PEDro scale. A qualitative review was performed and the studies' results were synthesized into five main findings: fear-avoidance beliefs, depression symptoms, pain self-efficacy, psychological distress, and return to work (RTW).Conclusions: There is evidence that MDT has an association with improving fear-avoidance beliefs, pain self-efficacy, depression, and psychological distress. These results should be interpreted with caution as further high-quality randomized control trials addressing this topic are necessary due to the varying methodological and statistical constructs of the included studies.

Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background

Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors.

Methods

Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis.

Results

Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences).

Conclusions

Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Local and Widespread Pressure Pain Hyperalgesia Is Not Side Specific in Females with Unilateral Neck Pain that Can Be Reproduced during Passive Neck Rotation

Current evidence for widespread hyperalgesia in non-specific neck pain (NSNP) is unclear. It is currently recommended to group NSNP patients according to pain-provoking movements. The aim of this study was to investigate local and widespread pain sensitivity in females with unilateral NSNP that is reproducible during passive neck rotation compared with matched controls, and to compare the side specific effect of pain location on pressure pain sensitivity among females with unilateral NSNP. Thirty-six females with unilateral NSNP evoked during passive ipsilateral (n = 20) or contralateral (n = 16) rotation toward the painful side were compared with 20 controls. Participants reported their pain intensity at rest and during passive neck rotation and completed the Neck Disability Index. Pressure pain thresholds (PPTs) were assessed bilaterally over the anterior scalene; the sternocleidomastoid; the levator scapulae; lateral to the spinous process of C6; the median, ulnar, and radial nerves; and the tibialis anterior. The ANOVA revealed lower PPTs in females with unilateral NSNP compared with the controls (all at p < 0.001), but no differences were found between the sides, nor was there any Group × side interaction. Among females with NSNP, those with higher pain intensity during ipsilateral rotation toward the painful side showed lower PPTs over the anterior scalene, median nerve, ulnar nerve, and tibialis anterior (all, p < 0.05) than females with higher pain intensity during contralateral rotation toward the painful side. These findings demonstrated bilateral local and widespread pressure pain hyperalgesia in females with unilateral NSNP that was reproducible during passive neck rotation compared with controls. There was no side specific effect of pain location on PPTs among females with unilateral NSNP.

Hybrid Approach to Treatment Tailoring for Low Back Pain: A Proposed Model of Care

Various approaches have been used to guide the treatment of low back pain. These approaches have been considered in isolation and often tested against each other. An alternative view is that a model of care that involves a hybrid approach may benefit patients with low back pain. This commentary considers the potential benefits of a sequentially applied hybrid approach for treatment tailoring to optimize resource allocation to those most likely to require comprehensive care, and then decision making toward treatment paths with the greatest potential for success. In a first step, a prognosis-based approach, such as the Subgroups for Targeted Treatment Back Screening Tool (STarT Back), identifies individuals likely to require greater resource allocation. Although a clear path is indicated toward simple and psychologically informed care for the low- and high-risk groups, respectively, there is limited guidance for the large medium-risk group. For that group, the hybrid model provides a stepwise path of additional methods to guide treatment selection. This includes subgrouping based on pain mechanism to guide priority domains for the next phase, which includes tailoring of psychological and movement-based approaches. Motor control approaches to exercise would be indicated for individuals with medium risk and a nociceptive pain mechanism, with treatment guided by detailed assessment via one of several paradigms. Psychologically informed treatments are tailored to those with medium risk and a predominantly central pain mechanism, guided by detailed assessment of psychosocial features. A hybrid approach to a model of care could simplify treatment selection and take advantage of the benefits of each method in a time- and cost-efficient manner. J Orthop Sports Phys Ther 2019;49(6):453-463. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8774.

Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain

Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.

Is the Organization of the Primary Motor Cortex in Low Back Pain Related to Pain, Movement, and/or Sensation?

AIM/BACKGROUND

Primary motor cortex (M1) organization differs between individuals with and without chronic low back pain (CLBP), in parallel with motor and sensory impairments. This study investigated whether movement behaviour and tactile/pain sensation are related to M1 organisation in CLBP.

METHODS

Transcranial magnetic stimulation (TMS) was used to map the M1 representation of the erector spinae and multifidus muscles in 20 participants with and without CLBP. Cortical organisation was quantified by: map volume; center of gravity (CoG); number of peaks; and primary and secondary peak location. Movement behaviour was assessed as the ability to dissociate lumbar from thorax motion and sensory function as two-point discrimination, pressure pain thresholds, and pain intensity (visual analogue scale).

RESULTS

People with CLBP showed more anterior location of the CoG than controls. Map peaks were more numerous in CLBP participants who performed the movement task good than those with poor performance. In CLBP, smaller map volume correlated with greater pain during the movement task. Movement behaviour was not linearly correlated with M1 features.

CONCLUSIONS

This study confirms that M1 maps differ between people with and without CLBP, but these changes are variable within the CLBP group and are not related to motor and sensory features in a simple manner.

Evidence of stabilizing exercises for low back- and pelvic girdle pain - a critical review

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

METHODS

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

CONCLUSION

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.

Effect of subgroup-specific multimodal therapy on chronic spinal back pain and function-a prospective inpatient multicentre clinical trial in Germany

Treatment modalities of spinal pain patients are discussed diversely, and different multimodal therapy programs have been developed. Purpose of the present study was to evaluate therapy outcome and effectiveness of an inpatient interdisciplinary and multimodal treatment program.This prospective multicentre clinical trial has been performed with patients from orthopedic hospitals receiving a functional musculoskeletal therapy pathway. Outcome measures were pain intensity and back-specific function (Oswestry Disability Index) before (T1) and after the intervention (T2) as well as after 6 and 12 months (T3, T4). Statistical approach included parametric (t test) and nonparametric (Wilcoxon-test) tests and the calculation of effect sizes. Additionally, a statistical subgroup analysis based on selected parameters (degree of pain chronicity, gender, and age) was performed using linear mixed models.In total, 249 patients (42.6% men, 57.4% women) with spinal pain were included, 133 patients were accessible for follow-up at T3 and 106 patients at T4.Average pain (AP) reduced significantly (P <.001) from T1 to T4 with an effect size of 0.99. Back-specific function also improved (P <.001) over all measuring time points (TP) (effect size: 0.63). Furthermore, the statistical subgroup analysis demonstrated the efficacy of the treatment concept within the subgroup parameters chronicity degree and age.A functional musculoskeletal therapy pathway including treatment of musculoskeletal dysfunctions appears to be beneficial in terms of treating pain and function. Pain chronicity and age seems to be factors influencing therapy outcome. Further studies are needed to examine the superiority of these inpatient programs for back pain including control groups.

Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain? A systematic review

Objectives: The purpose of this systematic review was to determine if movement-based classification (MBC) systems are more effective than therapeutic exercise or guideline-based care (GBC) in improving outcomes in patients with low back pain (LBP) based upon randomized clinical trials (RCT) with moderate to high methodological quality and low to moderate risk of bias. Methods: The search strategy was developed by a librarian experienced in systematic review methodology and peer reviewed by a second research librarian. The following databases were searched from their inception to May 17, 2018: PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. The identified RCTs with a PEDro score of ≥6 were screened and assessed for risk of bias by two blinded individual reviewers using Covidence. Results: Seven studies were identified that had moderate-to-high methodological quality. One of the studies was identified as having a high risk of bias. Of the six studies that remained, only one study reported finding a statistically significant difference at the immediate follow-up that was not clinically significant. There was no significance at 6 and 12 months. Discussion: There is a paucity of moderate to high methodological quality RCTs with similar methodology that compare MBC to standard of care treatments for patients with LBP. Studies with moderate to high methodological quality that have a low risk of bias do not support MBCs as being superior to general exercise or GBC in the treatment of nonradicular LBP. Level of Evidence: 1a.

Subgroups of lumbo-pelvic flexion kinematics are present in people with and without persistent low back pain

BACKGROUND

Movement dysfunctions have been associated with persistent low back pain (LBP) but optimal treatment remains unclear. One possibility is that subgroups of persistent LBP patients have differing movement characteristics and therefore different responses to interventions. This study examined if there were patterns of flexion-related lumbo-pelvic kinematic and EMG parameters that might define subgroups of movement.

METHODS

This was a cross-sectional, observational study of 126 people without any history of significant LBP and 140 people with persistent LBP (n = 266). Wireless motion and surface EMG sensors collected lumbo-pelvic data on flexion parameters (range of motion (ROM) of trunk, lumbar, and pelvis), speed, sequence coordination and timing, and EMG extensor muscle activity in forward bending (flexion relaxation)), and sitting parameters (relative position, pelvic tilt range and tilt ratio). Latent class analysis was used to identify patterns in these parameters.

RESULTS

Four subgroups with high probabilities of membership were found (mean 94.9%, SD10.1%). Subgroup 1 (n = 133 people, 26% LBP) had the greatest range of trunk flexion, fastest movement, full flexion relaxation, and synchronous lumbar versus pelvic movement. Subgroup 2 (n = 73, 71% LBP) had the greatest lumbar ROM, less flexion relaxation, and a 0.9 s lag of pelvic movement. Subgroup 3 (n = 41, 83% LBP) had the smallest lumbar ROM, a 0.6 s delay of lumbar movement (compared to pelvic movement), and less flexion relaxation than subgroup 2. Subgroup 4 (n = 19 people, 100% LBP) had the least flexion relaxation, slowest movement, greatest delay of pelvic movement and the smallest pelvic ROM. These patterns could be described as standard (subgroup 1), lumbar dominant (subgroup 2), pelvic dominant (subgroup 3) and guarded (subgroup 4). Significant post-hoc differences were seen between subgroups for most lumbo-pelvic kinematic and EMG parameters. There was greater direction-specific pain and activity limitation scores for subgroup 4 compared to other groups, and a greater percentage of people with leg pain in subgroups 2 and 4.

CONCLUSION

Four subgroups of lumbo-pelvic flexion kinematics were revealed with an unequal distribution among people with and without a history of persistent LBP. Such subgroups may have implications for which patients are likely to respond to movement-based interventions.

McKenzie mechanical syndromes coincide with biopsychosocial influences, including central sensitization: a descriptive study of individuals with chronic neck pain

BACKGROUND

Mechanical diagnosis and therapy (MDT) aims to assess and classify patients into theoretically mutually exclusive subgroups, in order to direct treatment. However, the latest evidence for biopsychosocial influence-central sensitization (CS) and psychological distress-have not been assessed in conjunction with MDT.

OBJECTIVES

(1) Determine the percentage of patients categorized into the MDT subgroups; (2) characterize the biopsychosocial clinical profile (presence of CS and psychological distress); and (3) identify associations between pain, disability, and biopsychosocial influences among this cohort.

METHODS

Eighty four patients with chronic neck pain were recruited by 10 certified MDT therapists using a convenience (consecutive) sampling method. Patients were evaluated using MDT principles and also completed an online survey to measure CS (using the Central Sensitization Inventory [CSI]), pain catastrophizing and kinesiophobia.

RESULTS

The proportions of the subgroups derangement (DER), dysfunction, postural and 'other' were 74.4, 2.4, 1.2, 20.7%, respectively. CS was observed in 62% of our sample (CSI score ≥ 40). CS was also observed in 64.7% of patients of the DER subgroup. Almost half of our sample (47.8%) demonstrated the co-occurrence of CS and DER, while 38% presented with DER syndrome, CS, and kinesiophobia.

CONCLUSION

The majority of our patients were classified as DER; they also presented with high levels of CS and/or psychological distress. This suggests that MDT mechanical subgroups, particularly DER, can present with co-occurring biopsychosocial influences. Without assessing CS and psychological distress, MDT therapists may miss crucial information. Further research is required to determine the optimal management of patients presenting with mechanical and non-mechanical drivers of pain.

Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis

Study Design Literature review with meta-analysis. Background The McKenzie Method of Mechanical Diagnosis and Therapy (MDT), a classification-based system, was designed to classify patients into homogeneous subgroups to direct treatment. Objectives To examine the effectiveness of MDT for improving pain and disability in patients with either acute (less than 12 weeks in duration) or chronic (greater than 12 weeks in duration) low back pain (LBP). Methods Randomized controlled trials examining MDT in patients with LBP were identified from 6 databases. Independent investigators assessed the studies for exclusion, extracted data, and assessed risk of bias. The standardized mean difference (SMD) and 95% confidence interval were calculated to compare the effects of MDT to those of other interventions in patients with acute or chronic LBP. Results Of the 17 studies that met the inclusion criteria, 11 yielded valid data for analysis. In patients with acute LBP, there was no significant difference in pain resolution (P = .11) and disability (P = .61) between MDT and other interventions. In patients with chronic LBP, there was a significant difference in disability (SMD, -0.45), with results favoring MDT compared to exercise alone. There were no significant differences between MDT and manual therapy plus exercise (P>.05) for pain and disability outcomes. Conclusion There is moderate- to high-quality evidence that MDT is not superior to other rehabilitation interventions for reducing pain and disability in patients with acute LBP. In patients with chronic LBP, there is moderate- to high-quality evidence that MDT is superior to other rehabilitation interventions for reducing pain and disability; however, this depends on the type of intervention being compared to MDT. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(6):476-490. Epub 30 Mar 2018. doi:10.2519/jospt.2018.7562.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative

OBJECTIVE

The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

METHODS

The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

RESULTS

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

CONCLUSIONS

A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual's disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

Rehabilitation management of low back pain - it's time to pull it all together!

In the past, rehabilitation research initiatives for low back pain (LBP) have targeted outcome enhancement through personalized treatment approaches, namely through classification systems (CS). Although the use of CS has enhanced outcomes, common management practices have not changed, the prevalence of LBP is still high, and only selected patients meet the CS profile, namely those with a nociceptive context. Similarly, although practice guidelines propose some level of organization and occasionally a timeline of care provision, each mainly provides best practice for isolated treatment approaches. Moreover, there is no theoretical framework that has been proposed that guides the rehabilitation management process of mechanical LBP. In this commentary, we propose a model constituted of five domains (nociceptive drivers, nervous system dysfunction drivers, comorbidities drivers, cognitive–emotional drivers, and contextual drivers) grounded as mechanisms driving pain and/or disability in LBP. Each domain is linked to the International Classification of Functioning, Disability and Health, where once a patient is deemed suitable for rehabilitation, the clinician assesses elements of each domain in order to identify where the relative treatment efforts should be focused. This theoretical model is designed to provide a more comprehensive management overview, by appreciating the relative contribution of each domain driving pain and disability. Considering that the multiple domains driving pain and disability, and their interaction, requires a model that is comprehensive enough to identify and address each related issue, we consider that the proposed model has several positive implications for rehabilitation of this painful and highly prevalent musculoskeletal disorder.

Latent class analysis derived subgroups of low back pain patients - do they have prognostic capacity?

BACKGROUND

Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the 'comparator variables').

METHODS

This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above.

RESULTS

The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants' recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%-6.9% for pain intensity and from 6.8%-20.3% for disability, and highest at the 2 weeks follow-up.

CONCLUSIONS

Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

Differences in lumbar spine and lower extremity kinematics during a step down functional task in people with and people without low back pain

BACKGROUND

When functional movements are impaired in people with low back pain, they may be a contributing factor to chronicity and recurrence. The purpose of the current study was to examine lumbar spine, pelvis, and lower extremity kinematics during a step down functional task between people with and without a history of low back pain.

METHODS

A 3-dimensional motion capture system was used to analyze kinematics during a step down task. Total excursion of the lumbar spine, pelvis, and lower extremity segments in each plane were calculated from the start to end of the task. Separate analysis of variance tests (α=0.05) were conducted to determine the effect of independent variables of group and plane on lumbar spine, pelvis, and lower extremity kinematics. An exploratory analysis was conducted to examine kinematic differences among movement-based low back pain subgroups.

FINDINGS

Subjects with low back pain displayed less lumbar spine movement than controls across all three planes of movement (P-values=0.001-0.043). This group difference was most pronounced in the sagittal plane. For the lower extremity, subjects with low back pain displayed more frontal and axial plane knee movement than controls (P-values=0.001). There were no significant differences in kinematics among movement-based low back pain subgroups.

INTERPRETATION

People with low back pain displayed less lumbar region movement in the sagittal plane and more off-plane knee movements than the control group during a step down task. Clinicians can use this information when assessing lumbar spine and lower extremity movement during functional tasks, with the goal of developing movement-based interventions.

Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain

Background

Low back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.

Method

Adult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.

Results

The study comprised 1271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.

Conclusion

The QTFC identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals’ outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1495-3) contains supplementary material, which is available to authorized users.

The side of chronic low back pain matters: evidence from the primary motor cortex excitability and the postural adjustments of multifidi muscles

Hemispheric lateralization of pain processing was reported with overactivation of the right frontal lobe. Specifically in chronic low back pain (CLBP), functional changes in the left primary motor cortex (M1) with impaired anticipatory postural activation (APA) of trunk muscles have been observed. Given the connections between frontal and M1 areas for motor planning, it is hypothesized that the pain side could differently influence M1 function and APA of paravertebral multifidus (MF) muscles. This study aimed at testing whether people with right- versus left-sided CLBP showed different M1 excitability and APA. Thirty-five individuals with lateralized CLBP (19 right-sided and 16 left-sided) and 13 pain-free subjects (normative values) were tested for the excitability of MF M1 area (active motor threshold-AMT) with transcranial magnetic stimulation and for the latency of MF APA during bilateral shoulder flexion and during unilateral hip extension in prone lying. In the right-sided CLBP group, the AMT of both M1 areas was lower than in the left-sided group and the pain-free subjects; the latency of MF APA was shorter in bilateral shoulder flexion and in the left hip extension tasks as compared to the left-sided group. In CLBP, an earlier MF APA was correlated with lower AMT in both tasks. People with right-sided CLBP presented with increased M1 excitability in both hemispheres and earlier MF APA. These results likely rely on cortical motor adaptation related to the tasks and axial muscles tested. Future studies should investigate whether CLBP side-related differences have a clinical impact, e.g. in diagnosis and intervention.