The evolving role of physical therapists in the long-term management of chronic low back pain: longitudinal care using assisted self-management strategies

Person-centered care for musculoskeletal pain: Putting principles into practice

Person-centered care specifically focuses on the whole person and is an important component of contemporary care for people with musculoskeletal pain conditions. Evidence suggests however, that some clinicians experience difficulties with integrating person-centered care principles into their clinical practice. Therefore, the purpose of this masterclass is to provide a framework that enables clinicians to incorporate person-centered principles in their management of people with musculoskeletal pain conditions. To support clinicians in overcoming some of the reported obstacles, we provide practical recommendations aimed at putting principles of person-centered care into practice. The framework supporting clinicians' delivery of person-centered care in practice consists of three key-principles: A) a biopsychosocial understanding of the person's experience; B) person-focused communication; and C) supported self-management. The framework includes three phases: 1) identification and goal setting, 2) coaching to self-management, and 3) evaluation. Building a therapeutic relationship underpins these phases and is an overarching element that weaves through the key-principles and phases of the framework. We use a clinical case to illustrate the practical implementation of these recommendations.

Predictors of failure to achieve minimal clinical important difference for pain and disability after mechanical diagnosis and therapy (MDT)-based multimodal rehabilitation for neck pain: a retrospective analysis of 4998 patients

PURPOSE

To determine predictors of failure to achieve minimal clinical important difference (MCID) for pain and disability at discharge after mechanical diagnosis and therapy (MDT)-based multimodal rehabilitation for neck pain (NP).

METHODS

Pre- and post-treatment numerical pain rating scale (NPRS) and neck disability index (NDI) in patients with mechanical NP were analysed in this retrospective study. Multivariate analysis was performed to investigate the effect of covariates such as age, gender, lifestyle, body mass index, presentation, diabetes, osteoporosis, response to repeated movement testing, treatment sessions, compliance rate, and pre-treatment NPRS and NDI scores on failure to achieve MCID of ≥ 30% for NPRS and NDI scores post-treatment.

RESULTS

In the 4998 patients analysed for this study, 7% and 14.5% of patients failed to achieve MCID for NPRS and NDI scores, respectively, at the end of treatment. Age > 70 years, diabetes, osteoporosis, partial or non-response to repeated movements, lesser treatment sessions, and lower compliance rate were associated with increased risk for failure to achieve MCID for NPRS and NDI scores. A higher pre-treatment NDI score was associated with failure to achieve MCID for NPRS score, whereas lower pre-treatment NPRS and NDI scores were associated with failure to achieve MCID for NDI score.

CONCLUSION

Although MDT-based multimodal rehabilitation helped to achieve significant reduction in pain and disability in mechanical NP, several baseline risk factors were associated with failure to achieve MCID for pain and disability after treatment. Identifying and modifying these factors as part of rehabilitation treatment may help to achieve better outcomes in mechanical NP.

Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person

Musculoskeletal rehabilitation, including physiotherapy, needs to move towards a broader biopsychosocial understanding of musculoskeletal conditions and the delivery of high-value care for people with persistent pain conditions, in which a patient-centered approach is a key feature. However, it has been reported that clinicians experience difficulties with integrating patient-centered care principles into their clinical practice. Based on a focused symposium about patient-centered care for patients with musculoskeletal conditions, held during the online 2021 World Physiotherapy Congress, the purpose of this article is to share key elements of the content of this symposium with a wider audience, aimed at enabling clinicians to enhance patient-centeredness in their current practice. These key elements include establishing meaningful connections, deciding together and self-management support. Moreover, challenges on patient-centered care in low/middle income countries will be discussed and recommendations to implement patient-centered care in clinical practice will be provided.

Outcomes of Participatory Ergonomics and Self-management in Commercial Clam Farmers with Chronic Low Back Pain: A Feasibility Study

PURPOSE

Participatory ergonomics engages workers in the development of strategies to reduce workplace-related pain, offering a flexible and practical option to create individualized context-specific strategies. This paper describes the outcomes of a feasibility study using a participatory approach for self-management of low back pain in clam farmers.

METHODS

A within-subject time-control design with repeated baseline and post-intervention assessment was used. After refining individual and team-based strategies, stakeholder interviews, and rapid prototyping, workers selected three strategies to use for 8 weeks. Frequency and ease of use for strategies are described. Pre-post paired t-tests were used for analysis of pain-related disability, difficulty and pain with work tasks, pain-related fear, self-efficacy, and coping. Analysis of improvements exceeding published and individual variability was calculated.

RESULTS

Participants chose both team and individual strategies, most using strategies 5 days a week >50% of the time. Significant improvements in pain-related disability, pain during specific tasks, pain-related anxiety, and coping were seen after 8 weeks of implementing strategies. No changes in task difficulty, fear, self-efficacy and average resting pain were reported. Pain improvements > MDC₉₅ were reported by 74% with 56-64% > personalized MDC₉₅ for lifting tasks.

CONCLUSIONS

Pain-related disability, work activity pain ratings and related pain anxiety and coping improved beyond individual variability in this feasibility study. Multiple strategies allowed workers to choose relevant self-management options. Introduction of work-related changes in the workplace, visual demonstration, review of team videos and reminders were helpful. Further studies of this approach are needed.

A cross-sectional study on fear-avoidance beliefs and chronic low back pain in fighter pilots

Background

Chronic low back pain (CLBP) is considered a serious complaint among fighter pilots because the vertebrae of these pilots are exposed to high compression forces from prolonged sitting on a hard ejection seat and frequent sudden fighter aircraft maneuvers. It is yet unknown whether a correlation exists between CLBP and psychosocial/behavioral performance of fighter pilots.

Methods

This was a cross-sectional study of 66 fighter pilots with nonspecific CLBP voluntarily participated in this study. Self-efficacy was measured based on the degree of physical activity and work performance using the fear-avoidance beliefs questionnaire (FABQ).

Results

A significant inverse correlation was found between the work subscale of the FABQ (FABQw) (mean score: 27.4 ± 8.4) and both age (mean: 35 ± 4.9 years) and flying experience (mean: 13.2 ± 4.4 years) among fighter pilots with nonspecific CLBP. In contrast, there was no significant correlation between physical activity subscale of the FABQ (mean score: 12.3 ± 6.4) and both age and flying experience.

Conclusions

An inverse correlation was observed between FABQw and both age and flying experience among fighter pilots with nonspecific CLBP. It is important for rehabilitation specialists to understand the role of cognitive/affective components of a pain from tissue injury and nociception to prevent occupational disability and enhance occupational performance.

Association between patient independence in performing an exercise program and adherence to home exercise program in people with chronic low back pain

BACKGROUND

A high percentage of patients with chronic low back pain (LBP) do not adequately adhere to home exercise programs. There is no information regarding a possible association between patient independence in performing an exercise program and adherence to this exercise program.

OBJECTIVE

To assess a possible association between patient independence in performing two different home exercise programs (treatment based on the Movement System Impairment-Based classification model (MSI) and treatment based on stretching and strengthening exercises for chronic LBP and adherence to those exercise programs.

DESIGN

This was a secondary analysis of a randomized controlled trial.

METHODS

The physical therapist assessed the patient's independence in performing the exercise program at the initial physical therapy sessions. Adherence was calculated during the 8-week treatment by the number of days performing the home exercise programs. Multivariate linear regression models were built to investigate whether patient independence in performing the home exercise program was associated with adherence to home exercise program for each treatment group adjusted for possible confounders (age, physical activity status, pain duration, pain intensity and disability at baseline).

RESULTS

We observed a clinically important association between patient independence in performing the home exercise and adherence to a treatment based on the MSI model group (ß = -15.6 days, 95%CI = -24.5 to -6.7, R² = 16%, p = 0.001).

CONCLUSIONS

People with chronic LBP adhered more to a home exercise program based on the MSI model when they are more independent in performing the exercise program.

The impact of low back pain systematic reviews and clinical practice guidelines measured by the Altmetric score: Cross-Sectional study

BACKGROUND

Although Altmetric has been widely used by researchers to monitor the audience of their articles, there are no studies that have analysed factors associated with Altmetric score for systematic reviews and clinical practice guidelines.

OBJECTIVES

1) To analyse factors that could be associated with Altmetric scores for low back pain systematic reviews and clinical practice guidelines. 2) To describe the characteristics of these articles and their Altmetric scores.

METHODS

We searched for all low back pain systematic reviews and guidelines indexed on the Physiotherapy Evidence Database published between 2015 and 2017. We extracted data related to the published paper, the publishing journal, and Altmetric scores.

RESULTS

A total of 66 systematic reviews and 5 guidelines were included. The variable impact factor (independent variable) was associated with Altmetric mentioned score (dependent variable) with a β coefficient of 15.4 (95% CI: 0.97, 29.7) ajusted to all remaining variables. The variable number of citations normalized by year of publication (independent variable) was associated with Altmetric reader score (dependent variable) with a β coefficient of 6.4 (95% CI: 4.03, 8.72) ajusted to all remaining variables. We also found that the majority of the systematic reviews and guidelines were published in English, had a descriptive title, were published as open access, included multicenter studies, and had media release generated by the publishing journal.

CONCLUSION

Metrics related to the number of citations, such as the impact factor are associated with Altmetric scores.

Active Long-term Care Strategies in a Group Setting for Chronic Spine Pain in 3 United States Military Veterans: A Case Series

Objective

The purpose of this article is to describe the management of chronic spine pain in 3 United States military veterans who participated in extended courses of chiropractic care that focused on active care strategies in a group setting.

Clinical Features

A 68-year old male veteran (case 1) with a 90% service-connected disability rating presented with chronic neck and lower back pain. An 82-year old male veteran (case 2) with a 20% service-connected disability rating presented with chronic neck and upper back pain. A 66-year old male veteran (case 3) presented with a 10% service-connected disability with chronic episodic back and neck pain. Each veteran described a desire to maintain ongoing chiropractic treatments after completion of a course of chiropractic care in which maximal therapeutic gain had been determined. Patient-Reported Outcomes Measurement Information System (PROMIS) Patient Interference Short Form 6b (PPI), PROMIS Physical Function Short Form 10b (PPF), and Pain, Enjoyment, and General Activity (PEG) outcome measurement tools were used to track response to care.

Interventions and Outcome

Each veteran participated in an extended course of chiropractic visits consisting of group pain education, group cognitive behavioral strategies, group exercise, group mind-body self-regulation therapy, and optional individual manual therapy. Case 1 completed 8 extended chiropractic visits in 12 months and reported no change in PPI scores, improvement in PPF scores, and worsening PEG scores. Cases 2 and 3 completed 6 extended chiropractic visits each over a 12-month period and reported improvements in PPI, PPF, and PEG scores.

Conclusion

This article describes the responses of 3 veterans with chronic spine pain participating in long-term care using chiropractic visits in a group setting that focused on active care strategies. Our group-based, active care approach differs from those described in literature, which commonly focus on visits with a strong emphasis on manual therapy in 1-on-1 patient encounters.

Factors associated with the reporting quality of low back pain systematic review abstracts in physical therapy: a methodological study

BACKGROUND

Abstracts of systematic reviews (SR) are frequently used to guide clinical decision-making. However, if the abstract is inadequately reported, key information may be missing and it may not accurately summarize the results of the review.

OBJECTIVE

We aimed to investigate 1) if abstracts are fully reported; 2) if abstract reporting is associated with review/journal characteristics in physical therapy for low back pain (LBP); and 3) if these abstracts are consistent with the corresponding full texts.

METHODS

We searched the Physiotherapy Evidence Database for SRs in physical therapy for LBP published between 2015 and 2017. Associations between abstract reporting quality and review/journal characteristics were explored with linear regression. Abstract reporting was assessed with the 12 item Preferred Reporting Items for Systematic Reviews and Meta-Analyses for abstracts (PRISMA-A) checklist. Consistency of reporting between abstracts and the full text was evaluated by comparing responses to each item of the PRISMA-A using Kappa coefficients. Methodological quality of the reviews was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2).

RESULTS

We included 66 SRs, 9 Cochrane and 57 non-Cochrane. Review methodological quality ranged from 'high' (8%) to 'critically low' (76%). The mean ± SD of the "total number of PRISMA-A fully reported items" (range 0-12 points for fully reported items) was 4.1 ± 1.9 points for non-Cochrane review abstracts and 9.9 ± 1.1 points for Cochrane abstracts. Factors associated with reporting quality of abstracts were: journal impact factor (ß 0.20; 95% CI: 0.06, 0.35), number of words in abstract (ß 0.01; 95% CI: 0.00, 0.01) and review methodological quality ('critically low' with ß -3.06; 95% CI: -5.30, -0.82; with 'high' as reference variable). There was typically inconsistent reporting between abstract and full text, with most Kappa values lower than 0.60.

CONCLUSIONS

The abstracts of SRs in physical therapy for LBP were poorly reported and inconsistent with the full text. The reporting quality of abstracts was higher in journals with a higher impact factor, in abstracts with a greater number of words, and when the review was of higher methodological quality.

Eight in Every 10 Abstracts of Low Back Pain Systematic Reviews Presented Spin and Inconsistencies With the Full Text: An Analysis of 66 Systematic Reviews

STUDY DESIGN

Overview study.

BACKGROUND

Abstracts of systematic reviews have presented 'spin' (i.e. overstated interpretation of study results) and inconsistency with the full text.

OBJECTIVES

1. Do abstracts of low back pain reviews contain spin? 2. Do these abstracts consistently represent the full text? 3. Is abstract spin associated with the type of conclusion?

METHODS

We searched the Physiotherapy Evidence Database (PEDro) on 10th January 2018. Data were extracted from systematic reviews of physiotherapy interventions for low back pain, published between 2015 and 2017. Spin was assessed using a 7-item checklist. We evaluated consistency by comparing information contained in the abstract and the full text using the 7-item checklist with Kappa coefficient analysis. We used logistic regression analysis to evaluate the association between spin in the abstract and type of conclusion. We evaluated methodological quality using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews).

RESULTS

We included 66 eligible systematic reviews, subdivided into Cochrane (n=9) and non-Cochrane (n=57) reviews. There was some form of spin in 80% of abstracts. Abstracts of non-Cochrane reviews were not consistent with the full text (fair to moderate agreement). Cochrane review abstracts had substantial to almost perfect agreement with the full text. Spin was not associated with the type of conclusion in all systematic reviews (P < 0.05). The methodological quality ranged from 'high' to 'critically low'.

CONCLUSIONS

The abstracts of systematic reviews evaluating physiotherapy interventions for low back pain need improvement. J Orthop Sports Phys Ther, Epub 23 Aug 2019. doi:10.2519/jospt.2020.8962.

Effect of Low Back Pain Chronicity on Patient Outcomes Treated in Outpatient Physical Therapy: A Retrospective Observational Study

OBJECTIVE

To examine the potential relationship between physical therapy (PT) treatment outcomes and chronicity of low back pain (LBP) in the outpatient setting.

DESIGN

Retrospective observational study.

SETTING

Outpatient PT clinics across 11 states.

PARTICIPANTS

A total of 11,941 patients with LBP provided with PT services and discharged from care between January 1, 2017, and December 31, 2018.

MAIN OUTCOME MEASURES

Focus on Therapeutic Outcome Low Back Functional Status (FS) Patient-Reported Outcome Measure (PROM) was the primary outcomes measure used. It assesses the patients' perceived physical abilities for patients experiencing LBP impairments. It determined a functional score on a linear metric ranging from 0 (low functioning) to 100 (high functioning). The difference in score between the intake FS and final FS score produced the FS change, which represented the overall improvement of the episode of care.

RESULTS

The mean FS change was 16.997 (n=11,945). Patients with chronic symptoms (>90-d duration) had an FS change of 15.920 (n=7264) across 14.63 visits. Patients with subacute symptoms (15-90d) had an FS change of 21.66 (n=3631) across 14.05. Patients with acute symptoms (0-14d) had an FS change of 29.32 (n=1050) across 13.66 visits. Stepwise regression analysis revealed a significant â for chronicity (-4.155) with all models.

CONCLUSIONS

Overall, this study shows patients experiencing shorter duration of LBP symptoms before starting a PT episode of care experience significantly better outcomes than patients who waited. Furthermore, the number of treatment session and duration of care was similar between groups, indicating potential ineffective or insufficient care was provided for patients with chronic pain.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms

OBJECTIVE

Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS.

METHODS

A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning.

RESULTS

Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning.

CONCLUSION

This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.

Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists

Persistent musculoskeletal pain is a worldwide health problem resulting in negative effects on individuals' wellbeing and substantial costs to society. Recently, there has been discussion about effective treatment approaches to persistent musculoskeletal disorders, including low back pain. In this Viewpoint, the authors argue that self-management strategies are essential to the management of persistent musculoskeletal disorders and outline the physical therapist's role in supporting effective self-management. J Orthop Sports Phys Ther 2019;49(4):212-215. doi:10.2519/jospt.2019.0605.

Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study

BACKGROUND

Physiotherapists have been urged to embrace a patient-oriented biopsychosocial (BPS) framework for the management of non-specific chronic low back pain (NSCLBP). However, recent evidence suggests that providing broader BPS interventions demonstrates small differences in pain or disability compared to usual care. Little is known about how to integrate a BPS model into physiotherapy practice and the challenges it presents.

OBJECTIVE

To explore the perceptions of physiotherapists' in primary care in England adopting a BPS approach to managing NSCLBP patients.

METHOD

Qualitative semi-structured interviews were conducted with ten physiotherapists working in primary care. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes.

RESULTS

Three main themes emerged: (1) physiotherapists recognised the multi-dimensional nature of NSCLBP and the need to manage the condition from a BPS perspective, (2) addressing psychological factors was viewed as challenging due to a lack of training and guidance, (3) engaging patients to self-manage their NSCLBP was seen as a key objective.

CONCLUSION

Although employing a BPS approach is recognised by physiotherapists in the management of NSCLBP, this study highlights the problems of implementing evidence based guidelines recommending that psychological factors be addressed but providing limited support for this. It also supports the need to allocate more time to explore these domains in distressed individuals. Engaging patients to self-manage was seen as a key objective, which was not a straightforward process, requiring careful negotiation.

Description of low back pain clinical trials in physical therapy: a cross sectional study

OBJECTIVE

To describe the main characteristics of low back pain randomized controlled trials on the Physiotherapy Evidence Database, and to rank the journals where these trials were published according to their Impact Factor.

METHODS

This is a cross sectional study based on a collection of randomized controlled trials. A random sample of 200 low back pain trials published between 2010 and 2015 were selected from Physiotherapy Evidence Database in February 2016. We collected the following main characteristics of trials: 2015 journal Impact Factor; if the paper was published as open access; CONSORT recommendations endorsement by the journal; methodological quality and statistical reporting measured by the 0-10 items Physiotherapy Evidence Database scale. Data was analyzed descriptively.

RESULTS

Trials were published in journals with a mean Impact Factor of 2.5 (SD 2.5), from which 55.5% endorsed the CONSORT recommendations. The methodological quality was moderate with 5.8 points (SD 1.6). The top 3 journals according to Impact Factor were: (1) British Medical Journal; (2) Annals of Internal Medicine; and (3) BMC Medicine. Only 6 out of 97 journals publishing low back pain trials combined the following factors: journal Impact Factor higher than 2.0, mean trial methodological quality higher than 6.0 points, endorse CONSORT recommendations and offering papers as open access.

CONCLUSION

Clinicians interested in low back pain trials must look for a wide variety of healthcare journals. A substantial number of low back pain randomized controlled trials did not follow adequate reporting and methodological recommendations.

Can demographic and anthropometric characteristics predict clinical improvement in patients with chronic non-specific low back pain?

OBJECTIVE

To identify potential prognostic factors that may predict clinical improvement of patients treated with different physical therapy interventions in the short-term.

METHODS

This is a prospective cohort study. A total of 616 patients with chronic non-specific low back pain treated with interventions commonly used by physical therapists were included. These patients were selected from five randomized controlled trials. Multivariate linear regression models were used to verify if sociodemographic characteristics (age, gender, and marital status), anthropometric variables (height, body mass, and body mass index), or duration of low back pain, pain intensity at baseline, and disability at baseline could be associated with clinical outcomes of pain intensity and disability four weeks after baseline.

RESULTS

The predictive variables for pain intensity were age (β=0.01 points, 95% CI=0.00 to 0.03, p=0.03) and pain intensity at baseline (β=0.23 points, 95% CI=0.13 to 0.33, p=0.00), with an explained variability of 4.6%. Similarly, the predictive variables for disability after four weeks were age (β=0.03 points, 95% CI=0.00 to 0.06, p=0.01) and disability at baseline (β=0.71 points, 95% CI=0.65 to 0.78, p=0.00), with an explained variability of 42.1%.

CONCLUSION

Only age, pain at baseline and disability at baseline influenced the pain intensity and disability after four weeks of treatment. The beta coefficient for age was statistically significant, but the magnitude of this association was very small and not clinically important.

Hypnosis Enhances the Effects of Pain Education in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

The potential benefits of combining pain education (PE) with clinical hypnosis (CH) has not yet been investigated in individuals with chronic pain. A total of 100 patients with chronic nonspecific low back pain were randomized to receive either: 1) PE alone, or 2) PE with CH. Outcomes were collected by a blinded assessor at 2 weeks and 3 months after randomization. The primary outcomes were average pain intensity, worst pain intensity (both assessed with 11-point numeric rating scales), and disability (24-item Roland Morris Disability Questionnaire) at 2 weeks. At 2 weeks, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.35 points, 95% confidence interval [CI] = .32-2.37) and disability (mean difference = 2.34 points, 95% CI = .06-4.61), but not average pain intensity (mean difference = .67 point, 95% CI = -.27 to 1.62), relative to participants who received PE alone. PE with CH participants also reported more global perceived benefits at 2 weeks (mean difference = -1.98 points, 95% CI = -3.21 to -.75). At 3 months, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.32 points, 95% CI = .29-2.34) and catastrophizing (mean difference = 5.30 points, 95% CI = 1.20-9.41). No adverse effects in either treatment condition were reported. To our knowledge, this is the first trial showing that additional use of hypnosis with PE results in improved outcomes over PE alone in patients with chronic nonspecific low back pain.

PERSPECTIVE

This study provides evidence supporting the efficacy of another treatment option for teaching patients to self-manage chronic low back pain that has a relatively low cost and that can be offered in groups.

Impact of Low Back Pain Clinical Trials Measured by the Altmetric Score: Cross-Sectional Study

Background

There is interest from authors and publishers in sharing the results of their studies over the Internet in order to increase their readership. In this way, articles tend to be discussed and the impact of these articles tends to be increased. In order to measure this type of impact, a new score (named Altmetric) was created. Altmetric aims to understand the individual impact of each article through the attention attracted online.

Objective

The primary objective of this study was to analyze potential factors related with the publishing journal and the publishing trial that could be associated with Altmetric scores on a random sample of low back pain randomized controlled trials (RCTs). The secondary objective of this study was to describe the characteristics of these trials and their Altmetric scores.

Methods

We searched for all low back pain RCTs indexed on the Physiotherapy Evidence Database (PEDro; www.pedro.org.au) published between 2010 and 2015. A total of 200 articles were randomly selected, and we extracted data related to the publishing trial, the publishing journal, methodological quality of the trials (measured by the 0-10 item PEDro scale), and total and individual scores of Altmetric mentioned and Altmetric reader. The study was a cross-sectional study, and multivariate regression models and descriptive statistics were used.

Results

A total of four variables were associated with Altmetric mentioned score: impact factor (β-coefficient=3.4 points), number of years since publication (β-coefficient=–4.9 points), number of citations divided by years since publication (β-coefficient=5.2 points), and descriptive title (β-coefficient=–29.4 points). Only one independent variable was associated with Altmetric reader score: number of citations divided by years since publication (β-coefficient=10.1 points, 95% CI 7.74-12.46). We also found that the majority of articles were published in English, with a descriptive title, and published in open access journals endorsing the Consolidated Standards of Reporting Trials (CONSORT) statement.

Conclusions

Researchers should preferably select high impact factor journals for submission and use declarative or interrogative titles, as these factors are likely to increase the visibility of their studies in social media.

Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines?

BACKGROUND CONTEXT

Clinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal.

PURPOSE

The objectives of this study were to examine how many patients complaining of low back pain (LBP) underwent evidence-based medical interventional treatment in line with CPG recommendations before consultation with a spine surgeon, and to evaluate any associations between adherence to CPG recommendations and baseline factors.

STUDY DESIGN/SETTING

This is a cross-sectional cohort analysis at a tertiary care center.

PATIENT SAMPLE

A total of 229 patients were referred for surgical consultation for an elective lumbar spinal condition.

OUTCOME MEASURES

The outcome measures include the number of CPG-recommended treatments undertaken by patients at or before the time of referral, the validated pain score, the EuroQol-5D (EQ-5D) health status, and the Oswestry Disability Index (ODI) score.

METHODS

Questionnaires assessing demographic and functional characteristics as well as overall health care use were sent to patients immediately after their referral was received by the surgeon's office.

RESULTS

Medications were the most common modality before consultation (74.2% of patients), of which 46.3% received opioids. The number of medications taken was significantly related to a higher ODI score (R=0.23, p=.0004), a higher pain score (R=0.15, p=.026), and a lower EQ-5D health status (R=-0.15, p=.024). In contrast, a lower pain score (7.2 vs. 7.7, p=.037) and a lower ODI score (26.6 vs. 29.9, p=.0023) were associated with performing adequate amounts of exercise. There was a significant association between lower numbers of treatments received and higher numerical pain rating scores (R=-0.14, p=.035). The majority (61.1%) of patients received two or less forms of treatment.

CONCLUSIONS

Evidence-based medical interventional treatments for patients with LBP are not being taken advantage of before spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health system pathway changes are necessary.

Physical therapists familiarity and beliefs about health services utilization and health seeking behaviour

BACKGROUND

Physical therapists' familiarity, perceptions, and beliefs about health services utilization and health seeking behaviour have not been previously assessed.

OBJECTIVES

The purposes of this study were to identify physical therapists' characteristics related to familiarity of health services utilization and health seeking behaviour, and to assess what health seeking behaviour factors providers felt were related to health services utilization.

METHODS

We administered a survey based on the Andersen behavioural model of health services utilization to physical therapists using social media campaigns and email between March and June of 2017. In addition to descriptive statistics, we performed binomial logistic regression analysis. We asked respondents to rate familiarity with health services utilization and health seeking behaviour and collected additional characteristic variables.

RESULTS

Physical therapists are more familiar with health services utilization than health seeking behaviour. Those who are familiar with either construct tend to be those who assess for health services utilization, use health services utilization for a prognosis, and believe that health seeking behaviour is measurable. Physical therapists rated need and enabling factors as having more influence on health services utilization than predisposing and health belief factors.

CONCLUSION

Physical therapists are generally familiar with health services utilization and health seeking behaviour; however, there appears to be a disconnect between what is familiar, what is perceived to be important, and what can be assessed for both health services utilization and health seeking behaviour.

Effect of sacroiliac manipulation on postural sway in quiet standing: a randomized controlled trial

BACKGROUND

Sacroiliac joint manipulation can alter joint and muscle control mechanisms through local and remote effects. Postural balance is controlled by supraspinal (rambling) and spinal-peripheral (trembling) mechanisms. A manipulation may interfere with postural control in quiet standing.

OBJECTIVES

To evaluate the immediate effects of sacroiliac joint manipulation on postural control in patients with (1) sacroiliac dysfunction and (2) to determine whether rambling and trembling are affected by sacroiliac joint manipulation.

METHODS

32 patients aged between 20 and 50 years old were selected by convenience after confirmation of sacroiliac joint dysfunction by clinical examination. These patients were randomly allocated either to manipulation or sham manipulation group. Displacement, velocity and frequency of the center of pressure, rambling and trembling in the anterior-posterior and medial-lateral directions were our primary outcomes and analyzed immediately before and after the intervention in quiet standing. The physical therapists who performed the physical, biomechanical and statistical examinations, were all blinded to the patients' grouping.

RESULTS

No differences were found between the two groups but trembling velocity (0.14 and -0.11 for intervention and sham group, respectively) and frequency (0.17 and 0.11 for intervention and sham group respectively) increased after intervention in the treatment group in the anterior-posterior direction.

CONCLUSION

Generally, sacroiliac joint manipulation had no superiority than sham treatment regarding postural control as measured by rambling-trembling analysis of center of pressure. Manipulation may increase muscle activation in the treatment group due to increased trembling parameters. Trial number: IRCT2014072715932N8 - http://www.irct.ir/searchresult.php?keyword=%D8%B3%D9%88%DB%8C%D9%87&id=15932&field=&number=8&prt=13&total=10&m=1.

Movement System Impairment-Based Classification Treatment Versus General Exercises for Chronic Low Back Pain: Randomized Controlled Trial

Background

Treatment for chronic low back pain (LBP) includes different forms of exercises, that to date have resulted in only small to moderate treatment effects. To enhance the treatment effects, different classification systems have been developed to classify people with LBP into more homogeneous subgroups leading to specific treatments for each subgroup.

Objective

The purpose of this study was to compare the efficacy of a treatment based on the Movement System Impairment (MSI) model with a treatment consisting of symptom-guided stretching and strengthening exercises in people with chronic LBP.

Design

The study was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor.

Setting

The study setting was a university physical therapy clinic in Brazil.

Patients

A total of 148 participants with chronic LBP participated in the study.

Interventions

Participants were randomly allocated to an 8-week treatment of either treatment based on the MSI-based classification system or symptom-guided stretching and strengthening exercises.

Measurements

Measures of pain intensity, disability, and global impression of recovery were obtained by a blinded assessor at baseline and at follow-up appointments at 2, 4, and 6 months after randomization.

Results

There were no significant between-group differences for the primary outcomes of pain intensity at 2 months (mean difference = 0.05, 95% CI = –0.90 to 0.80) and disability at 2 months (mean difference = 0.00, 95% CI = –1.55 to 1.56). There also were no statistically significant differences between treatment groups for any of the secondary outcome measures.

Limitations

Participants and physical therapists were not masked.

Conclusions

People with chronic LBP had similar improvements in pain, disability, and global impression of recovery with treatment consisting of symptom-guided stretching and strengthening exercises and treatment based on the MSI model.

Adherence to Back Pain Clinical Practice Guidelines by Brazilian Physical Therapists: A Cross-sectional Study

STUDY DESIGN

This was a cross-sectional observational study.

OBJECTIVES

(i) to investigate whether Brazilian physical therapists make clinical decisions for patients with low back pain based upon clinical practice guidelines and (ii) to determine whether the physical therapists are able to recognize differential diagnoses of low back pain associated with red or yellow flags.

SUMMARY OF BACKGROUND DATA

Early adherence to clinical practice guidelines may accelerate recovery and reduce the costs associated with low back pain. It is unknown whether Brazilian physical therapists follow clinical practice guidelines to make their clinical decisions in the treatment of patients with low back pain.

METHODS

The sample consisted of physical therapists from two Brazilian physical therapy associations. The data were collected via electronic survey and face-to-face interviews. The survey was composed of six hypothetical clinical cases of low back pain, which served as a basis to evaluate clinical decisions and adherence to clinical practice guidelines for low back pain. The study participants had 27 possible answers for each clinical case and could choose up to five answers. The results were analyzed in three ways: full adherence, partial adherence, or no adherence to the recommendations from clinical practice guidelines.

RESULTS

A total of 530 physical therapists were invited and 189 participated in the study (response rate = 35.6%). Full adherence to the guidelines was low for all six cases (rates ranging from 5%-24%). Partial adherence to the guidelines was higher when compared with full adherence (rates ranging from 32%-75%). The participants were more likely to identify differential diagnoses associated with yellow flags than with red flags.

CONCLUSION

Brazilian physical therapists are not using the best available evidence in their clinical decision making for patients with low back pain. Wider dissemination of clinical practice guidelines should be urgently undertaken.

LEVEL OF EVIDENCE

2.

Effects of photobiomodulation therapy in patients with chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

INTRODUCTION

Low back pain (LBP) is one of the largest and most frequent public health problems worldwide. Photobiomodulation therapy (PBMT) is a frequently used non-pharmacological therapy for the treatment of musculoskeletal disorders. However, there is little high-quality scientific evidence that demonstrates the effectiveness of PBMT in the treatment of patients with chronic LBP in the short, medium and long term. Therefore, the objective of this clinical trial is to evaluate the effects of PBMT in patients with chronic non-specific LBP in the short, medium and long term.

METHODS AND ANALYSES

This is a prospectively registered, two-arm randomised placebo-controlled trial with blinded patients, assessors and treatment providers. One hundred and forty-eight patients with chronic non-specific LBP will be recruited. Treatment sessions will be provided three times a week for 4 weeks (totaling 12 sessions) with patients receiving either placebo or active PBMT. For ethical reasons, all patients, regardless of treatment allocation, will also receive an information booklet based on 'The Back Book'. Clinical outcomes will be measured at baseline, at the end of treatment, as well as 3, 6 and 12 months after randomisation. The primary outcomes will be pain intensity and disability measured after 12 sessions of treatment. The secondary outcomes will be pain intensity and disability measured at 3, 6 and 12 months after randomisation, in addition to specific disability and global perceived effect in all time points.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee of Universidade Cidade de São Paulo. The results will be disseminated through scientific publications and presentations at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03089424.

Influence of allocation concealment and intention-to-treat analysis on treatment effects of physical therapy interventions in low back pain randomised controlled trials: a protocol of a meta-epidemiological study

INTRODUCTION

Meta-epidemiological studies examining the influence of methodological characteristics, such as allocation concealment and intention-to-treat analysis have been performed in a large number of healthcare areas. However, there are no studies investigating these characteristics in physical therapy interventions for patients with low back pain. The aim of this study is to investigate the influence of allocation concealment and the use of intention-to-treat analysis on estimates of treatment effects of physical therapy interventions in low back pain clinical trials.

METHODS AND ANALYSIS

Searches on PubMed, Embase, Cochrane Database of Systematic Reviews, Physiotherapy Evidence Database (PEDro) and CINAHL databases will be performed. We will search for systematic reviews that include a meta-analysis of randomised controlled trials that compared physical therapy interventions in patients with low back pain with placebo or no intervention, and have pain intensity or disability as the primary outcomes. Information about selection (allocation concealment) and attrition bias (intention-to-treat analysis) will be extracted from the PEDro database for each included trial. Information about bibliographic data, study characteristics, participants' characteristics and study results will be extracted. A random-effects model will be used to provide separate estimates of treatment effects for trials with and without allocation concealment and with and without intention-to-treat analysis (eg, four estimates). A meta-regression will be performed to measure the association between methodological features and treatment effects from each trial. The dependent variable will be the treatment effect (the mean between-group differences) for the primary outcomes (pain or disability), while the independent variables will be the methodological features of interest (allocation concealment and intention-to-treat analysis). Other covariates will include sample size and sequence generation.

ETHICS AND DISSEMINATION

No ethical approval will be required for this study. The study findings will be published in a peer-reviewed journal and presented at international conferences.

REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42016052347).

Functional disability in patients with low back pain: the mediator role of suffering and beliefs about pain control in patients receiving physical and chiropractic treatment

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Subjective suffering mediated the relationship between depression and functional disability regardless of the type of treatment.

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Beliefs about chance events mediated the relationship between depression and functional disability only in the physical therapy treatment.

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Intervention should target cognitive and psychological factors in LBP patients.

Background

Low back pain is the leading cause of disability worldwide. There is evidence that depression, anxiety, and external locus of control are negative predictors of functional disability in low back patients.

Methods

This study focused on the mediator role of suffering and beliefs about pain control in the relationship between psychological morbidity and functional disability in patients receiving physical therapy and chiropractic treatment for chronic low back pain. The sample included 213 patients receiving chiropractic treatment and 125 receiving physical therapy, who answered the following instruments: Beliefs about Pain Control Questionnaire; Inventory of Subjective Experiences of Suffering in Illness; Oswestry Low Back Pain Disability Questionnaire; and the Hospital Anxiety and Depression Scales.

Results

Suffering was a mediator in the relationship between depression and functional disability in both treatment groups. Only beliefs related to external chance events mediated the relationship between depression and functional disability in the physical therapy group, but not in the chiropratic teratment group.

Conclusion

Intervention should focus on suffering regardless of the type of treatment and target beliefs about pain control, in patients receiving physical therapy treatment since they seem to play a key role in functional disability in patients with low back pain.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up

Background

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP.

Methods

This was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment.

Results

The MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) −1.00, 95% CI −2.09 to −0.01) but not for disability (MD −0.84, 95% CI −2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events.

Conclusion

We found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times.

Trial registration number

ClinicalTrials.gov (NCT02123394)