Low back pain

Electrical Nerve Stimulation Induces Synaptic Plasticity in the Brain and the Spinal Cord: A Systematic Review

OBJECTIVES

This review aimed to compile the literature on synaptic plasticity induced by electrical nerve stimulation (ENS) in nociceptive and somatosensory circuits within the central nervous system, with a particular focus on its effects on both the brain and spinal cord. Understanding the mechanisms underlying synaptic changes, enhances our comprehension of how ENS contributes to both pain relief and the development of experimental pain models.

MATERIALS AND METHODS

We conducted a systematic search of PubMed, Scopus, PEDro, SciELO, and Cochrane databases, adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and evaluated the quality of evidence using SYRCLE's risk of bias tool. The inclusion criteria were application of ENS to peripheral nerves, reporting of a detailed methodology, providing direct physiological measurements of synaptic activity (eg, field potentials or intracellular recordings), and publication in English or Spanish. From 8094 results, 85 studies met the inclusion criteria.

RESULTS

ENS was found to induce synaptic potentiation in 70 studies, depression in 7, and both effects in 8. These outcomes were determined by specific stimulation parameters and individual characteristics, with distinct molecular mechanisms involved in each case. Notably, most research focused on long-term potentiation in nociceptive pathways to create experimental pain models, with most studies conducted in the spinal cord. Few studies explored the link between ENS-induced synaptic plasticity and its analgesic effects or the role of plasticity in supraspinal brain regions, suggesting promising areas for future research.

CONCLUSIONS

ENS-induced synaptic plasticity presents a valuable opportunity for both pain management and the development of experimental pain models. Further research is needed to explore the connections between plasticity, analgesia, and higher brain regions.

Global, Regional, and National Burden of Low Back Pain: Findings From the Global Burden of Disease Study 2021 and Projections to 2050

STUDY DESIGN

This was an observational study.

OBJECTIVE

Assessing the global burden of disease for low back pain (LBP) using the 2021 GBD (Global Burden of Disease) database.

SUMMARY OF BACKGROUND DATA

LBP is a leading cause of workforce loss and disability. With societal aging and changes in lifestyle and work habits, the incidence of LBP is expected to rise. This study comprehensively analyzes the epidemiological trends of global LBP from 1990 to 2021.

METHODS

Data publicly available from the 2021 GBD study were utilized, and a systematic analysis was conducted to assess the global burden and epidemiological trends of LBP.

RESULTS

From 1990 to 2021, the age-standardized prevalence, incidence, and Years Lived with Disability (YLD) rates of LBP have slightly declined globally. However, the number of affected individuals, new cases, and YLD numbers have significantly increased, making LBP a leading cause of YLD in 2021. The number of affected individuals increases with age, peaking in both men and women between the ages of 50 and 54. Worldwide, women have a higher prevalence of LBP than men, and this increases with age, with both sexes reaching peak prevalence between 80 and 84 years in 2021. Overall, over the past 3 decades, age-standardized YLD rates have shown a positive correlation with the Socio-demographic Index (SDI). In terms of region and nation, Tropical Latin America and Kingdom of Sweden have seen the greatest increase in age-standardized prevalence rates from 1990 to 2021.

CONCLUSION

Globally, LBP remains a notable public health concern, carrying a consistently high burden. To alleviate the future impact of this disease, it is imperative to increase public awareness regarding its risk factors and to implement preventive measures.

Implementation of the American- College of Physicians Guideline for Low Back Pain (IMPACt-LBP): protocol for a healthcare systems embedded multisite pragmatic cluster-randomised trial

INTRODUCTION

Low back pain (LBP) is a key source of medical costs and disability, impacting over 31 million Americans at any given time and resulting in US$100-US$200 billion per year in total healthcare costs. LBP is one of the leading causes of ambulatory care visits to US physicians; problematically, these visits often result in treatments such as opioids, surgery or advanced imaging that can lead to more harm than benefit. The American College of Physicians (ACP) Guideline for Low Back Pain recommends patients receive non-pharmacological interventions as a first-line treatment. Roadmaps exist for multidisciplinary collaborative care that include well-trained primary contact clinicians with specific expertise in the treatment of musculoskeletal conditions, such as physical therapists and doctors of chiropractic, as first-line providers for LBP. These clinicians, sometimes referred to as primary spine practitioners (PSPs) routinely employ many of the non-pharmacological approaches recommended by the ACP guideline, including spinal manipulation and exercise. Important foundational work has demonstrated that such care is feasible and safe, and results in improved physical function, less pain, fewer opioid prescriptions and reduced utilisation of healthcare services. However, this treatment approach for LBP has yet to be widely implemented or tested in a multisite clinical trial in real-world practice.

METHODS AND ANALYSIS

The Implementation of the American College of Physicians Guideline for Low Back Pain trial is a health system-embedded pragmatic cluster-randomised trial that will examine the effect of offering initial contact with a PSP compared with usual primary care for LBP. Twenty-six primary care clinics within three healthcare systems were randomised 1:1 to PSP intervention or usual primary care. Primary outcomes are pain interference and physical function using the Patient-Reported Outcomes Measurement Information System Short Forms collected via patient self-report among a planned sample of 1800 participants at baseline, 1, 3 (primary end point), 6 and 12 months. A subset of participants enrolled early in the trial will also receive a 24-month assessment. An economic analysis and analysis of healthcare utilisation will be conducted as well as an evaluation of the patient, provider and policy-level barriers and facilitators to implementing the PSP model using a mixed-methods process evaluation approach.

ETHICS AND DISSEMINATION

The study received ethics approval from Advarra, Duke University, Dartmouth Health and the University of Iowa Institutional Review Boards. Study data will be made available on completion, in compliance with National Institutes of Health data sharing policies.

TRIAL REGISTRATION NUMBER

NCT05626049.

Do clinical practice guidelines for low back pain include predatory journal or retracted publications? A meta-research study

BACKGROUND

Following clinical practice guidelines is widely recommended for treating many musculoskeletal diagnoses, including low back pain, but it is unknown if clinical practice guidelines for low back pain do.

OBJECTIVE

Assess whether clinical practice guidelines for low back pain reference publications from predatory journals or include retracted publications.

DESIGN

Meta-research.

METHODS

Clinical practice guidelines focusing on the management of adults with low back pain published between January 2010-June 2024 were included. All referenced publications in each guideline were evaluated for predatory categorization using a systematic process that included assessing publisher/journal websites, the Directory of Open Access Journals, Beall's List and major literature databases. The Retraction Watch Database was used to assess retraction status.

RESULTS

Nineteen clinical practice guidelines with 1617 unique publications met inclusion criteria. The majority of publications (1598/1617; 98.8 %) were categorized as 'non-predatory.' Fourteen publications (0.9 %) were categorized as 'predatory,' two (0.1 %) 'presumed predatory,' and three (0.2 %) were retracted. Four guidelines cited 'predatory' and/or 'presumed predatory' publications, and four guidelines cited the retracted publications.

CONCLUSION

Only 1.2 % of the cited publications included in clinical practice guidelines for the management of low back pain were deemed predatory or retracted, implying that guideline recommendations are unlikely to be influenced by their inclusion. There are currently no standard criteria for how to manage the inclusion of these publications in guidelines or systematic reviews. Future research should investigate the development of a valid and reliable checklist that allows authors to assess for and manage the presence of predatory or retracted publications.

The Arabic Oswestry Disability Index as a Unidimensional Measure: Confirmatory Factor Analysis

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate the structural validity of the Arabic version of the Oswestry disability index (ODI) in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The Arabic ODI is currently used in clinical and research settings to assess disability, but questions remain regarding its structural validity.

MATERIALS AND METHODS

Adult patients with LBP were recruited from physical therapy departments of two hospitals in Saudi Arabia. Participants completed the Arabic ODI and the numeric pain rating scale. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to examine the factor structure of the ODI. Maximum likelihood extraction and parallel analysis were used in the EFA, and the goodness-of-fit indices [χ 2 statistics, Tucker-Lewis index (TLI), comparative-fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean residual (SRMR)] were assessed in the CFA to confirm the factor structure.

RESULTS

A total of 113 patients (47.8% male, 52.2% female) participated. The EFA identified a unidimensional structure for the Arabic ODI, with one factor explaining 45.8% of the total variance. All items had significant factor loadings, with loadings ranging from 0.48 (sleeping) to 0.84 (sex life and social life). The CFA confirmed this unidimensional structure, yielding good fit indices [χ 2 =49.53, P <0.04; TLI=0.96; CFI=0.97; RMSEA=0.06 (90% CI=0.07-0.10), SRMR=0.04]. All ODI items exhibited significant positive loadings consistent with the expected correlation between the single latent variable (LBP-related disability) and the ODI items. A high error covariance was observed between items related to walking and standing.

CONCLUSION

The Arabic Oswestry disability index demonstrates sufficient structural validity as a unidimensional measure of disability in Arabic-speaking patients with low back pain. These findings support the continued use of the Oswestry disability index for disability assessment in clinical and research settings and support the validity of using one total score representing the single underlying latent construct.

LEVEL OF EVIDENCE

Level III.

Effects of a Postural Hammock in People with Chronic Neck Pain and Chronic Low Back Pain: A Randomized Controlled Trial

Background and Objectives: Musculoskeletal disorders (MD) affect over 1.7 billion people worldwide, with neck and low back pain being prevalent and debilitating conditions. Current treatments include various interventions, but novel approaches are needed to improve functionality and reduce disability. To evaluate the effects of a postural hammock on pain and functionality in people with chronic neck and low back pain. Materials and Methods: A randomized controlled trial was conducted with participants experiencing chronic neck and/or low back pain. They were assigned to either an experimental group using a postural hammock or a control group lying on a mat. Participants underwent five sessions of 10 min each over five consecutive days. Results: Forty-three subjects completed the study. While both groups showed improvements, the experimental group exhibited significant increases in hamstring flexibility and pain tolerance, measured through the Visual Analog Scale (VAS) and pressure pain thresholds (PPT). Postural hammock use demonstrated potential benefits in pain management and flexibility compared to conventional methods. Conclusions: Using a postural hammock may offer benefits for individuals with chronic back pain. Future research should explore combining hammock therapy with other interventions to enhance outcomes and improve the quality of life for patients with back pain.

Bibliometric analysis of research on manual therapy for low back pain from 2013 to 2023

BACKGROUND

Low back pain (LBP) is one of the most common symptoms prompting patients to seek treatment. Manual therapy is widely used to treat LBP. Nevertheless, there is a scarcity of bibliometric analyses examining the worldwide utilization of manual therapy for the treatment of LBP.

METHODS

This research used the Online Bibliometric overview Platform website (https://bibliometric.com), CiteSpace (6.2.R4), and VOSviewer (1.6.19) to provide a comprehensive analysis of the current status and prospective developments in the field. The Web of Science Core Collection (WOSCC) database was searched for publications from August 1, 2013, to August 1, 2023 on manual therapy of low back pain.

RESULTS

Among the identified articles, 488 fit the criteria. The number of papers on manual therapy for LBP has progressively risen over in the past 10 years, whereas the average number of citations of these papers has decreased. The leading countries producing publications on this discipline were the USA, Canada, and China. There were 345 authors of the studies, with Christine M. Goertz having the most publications. The University of Southern Denmark was the institution that contributed the most to the field. The Journal of Manipulative and Physiological Therapeutics published many of the research papers in this field. Keyword analysis showed that the relationship between low back pain, spinal manipulation, and management has been present throughout the development of this research area.

CONCLUSIONS

Spinal manipulation, management, randomized controlled trials, Physical therapy, care and disability are the current research hotspots in the treatment of LBP with manual therapy. In addition, research on complementary medicine and clinical practice guidelines may become an important trend in the future.

Risk factors and epidemiology of lower back pain among Bajaj drivers in Gondar City, northwestern Ethiopia: a community-based cross-sectional study

Objective. This study aimed to determine the prevalence and risk factors for lower back pain (LBP) among Bajaj drivers in Gondar City, northwestern Ethiopia. Methods. A community-based cross-sectional study was conducted in Gondar City. The collected data were entered into Epi Info version 7.2 and analyzed with SPSS version 20. The adjusted odds ratios (AORs) with p < 0.05 at the 95% confidence interval (CI) were reported and variables were considered to be significant risk factors. Results. The prevalence of LBP among Bajaj drivers was 49.2% (44.5-54.7%). Driver's age above 30 years (AOR 2.14, 95% CI [1.14, 4.01]), chewing chat (AOR 2.70, 95% CI [1.14, 6.21]), previous history of lower back trauma (AOR 1.68, 95% CI [1.29, 2.92]), no comfort in the seat (AOR 1.31, 95% CI [1.16, 4.60]), twisted sitting posture (AOR 1.39, 95% CI [1.03, 5.79]) and driving experience (AOR 1.52, 95% CI [1.08, 2.30]) were all significantly associated. Conclusion. Nearly half of the study participants had LBP, which was relatively common in the study area. According to the findings, the authors recommend that Bajaj drivers should have comfortable seats, maintain neutral sitting postures and take precautions while driving when they have a previous history of lower back trauma.

Two decades of the International Classification of Functioning, Disability and Health (ICF) in health research: a bibliometric analysis

Introduction: We conducted a twenty-year bibliometric analysis of scientific literature, focusing on the trends of The International Classification of Functioning, Disability and Health (ICF) use in health research.

Methods: We retrieved 3'467 documents published between 2002 and 2022, sourced from the Web of Science Core Collection database. We used the Bibliometrix and VoSviewer tools for descriptive analyses and data visualization.

Results: Our findings indicate a significant increase in ICF application since 2011, with an average annual growth rate of 13.19%. Prominent contributions were observed globally, with notable outputs from the U.S., Canada, Germany, the Netherlands, and Switzerland. The Ludwig Maximilian University Munich, Swiss Paraplegic Research, and McMaster University authored a quarter of the documents (24.6%). Collaboration networks of countries and institutions revealed robust partnerships, particularly between Germany and Switzerland. "Rehabilitation" was the most frequently occurring keyword, although a thematic shift towards epidemiology, aging, and health-related quality of life was observed post-2020. While rehabilitation remained the primary thematic focus, literature post-2020 highlighted epidemiology as a growing area of interest.

Conclusions: A steady increase in ICF-based research mirrors the rising interest in a biopsychosocial and person-centered approach to healthcare. However, the literature is primarily produced by high-resource countries, with underrepresentation from low and middle-resource countries, suggesting an area of future research to address this discrepancy.

Hip joint kinematic assessment in chronic non-specific low back pain patients. A Delphi study

BACKGROUND

Chronic nonspecific low back pain (CNSLBP) has been associated with movement impairment (MI) of the hip joint. However, evidence supporting this is inconsistent. Agreement from experts may provide rationale and recommendations for the assessment of the hip joint in the management of CNSLBP patients.

OBJECTIVE

Gain expert consensus on whether hip MIs are related to CNSLBP, whether they should be assessed and which movement types and directions they recommend.

METHODS

Through a three-round e-Delphi process, international experts in the field rated levels of agreement for generated themes pertaining to assessing proposed hip joint MI in individuals with CNSLBP and underlying rationales. Consensus was defined a priori as ≥75% ratings on Likert scales with an IQR≤ 1.

RESULTS

International expert panel consisted of a mix of researchers and clinicians with the majority involved in both. Response for round I was 27, round 2 was 21 and round III was 26 individuals. Consensus was achieved for the association of active and passive hip joint MI in CNSLBP and their assessment. 100% agreement was achieved for the rationale regarding compensatory movement of the lumbar spine, and the assessment of passive hip movements, in particular extension. Consensus was also achieved for assessing hip passive flexion, extension, rotations, and abduction, active flexion, extension, and abduction. No agreement was attained regarding passive accessory movement.

CONCLUSION

The assessment of active and passive hip joint MI is regarded by experts as appropriate and informative in the management of and research pertaining to CNSLBP.

Guideline concordant care for acute low back pain: A mixed-methods analysis of determinants of implementation

INTRODUCTION

We conducted an explanatory, sequential mixed-methods study to measure variation in the use of imaging and physical therapy (PT) for acute low back pain (LBP) and to identify implementation determinants that might explain variation in use across 22 EDs and 27 urgent cares in urban and rural locations within a community-based health system.

METHODS

We described the patient population and measured concordance with LBP guideline recommendations on imaging and PT referral from January-June 2023. We conducted key informant interviews with physicians and advanced practice providers (APPs), n = 30, from these 49 sites between July - September 2023 and performed content analysis to identify implementation determinants to guideline concordance.

RESULTS

From January-June 30, 2023, 1047 Intermountain Health employed or affiliated physicians and APPs at the 22 adult EDs and 27 adult UCs cared for 8047 patient encounters involving acute LBP with no red flags. 29% of acute LBP patient encounters included an imaging order (ED: 43%; UC: 18%) and 5% included a PT order (ED: 7%; UC: 4%). 17 ED and 13 UC physicians and APPs participated in semi-structured interviews. Their patient encounters represent 6% of the overall study population (ED: 5%; UC: 7%) with order rates and patient population characteristics similar to the full study population. ED and UC clinicians were generally familiar with LBP guideline recommendations but varied significantly in their knowledge and beliefs of the appropriate application of guidelines in evaluation and treatment plans.

DISCUSSION

Guideline concordance for use of imaging and PT varied substantially across physicians and advance practice providers providing care at EDs and UC centers within a community-based health system. Implementation strategies that address barriers identified by this study, including varied understanding of the PT discipline, complex workflows for placing PT referrals, the medico-legal assurance that imaging provides, and the lack of feedback loops in ED and UC centers should be tested in future hybrid implementation-effectiveness trials to increase concordance to LBP guidelines and minimize harm related to overuse of imaging and underuse of conservative first-line treatment approaches.

The PainSMART project: Protocol for a research program on effectiveness, mechanisms of effect and patient-practitioner experiences of the PainSMART-strategy as an adjunct to usual primary care physiotherapy management for musculoskeletal pain

BACKGROUND

Musculoskeletal pain (MSKP) disorders entail a significant burden for individuals and healthcare systems. The PainSMART-strategy has been developed aiming to reduce divergences between patients and healthcare practitioners in their understanding of MSKP by providing a shared basis for communication and to facilitate patients' self-management of MSKP. The objective of the PainSMART-project is to evaluate the effects of the PainSMART-strategy as an adjunct to usual physiotherapy management compared to usual physiotherapy management alone.

METHODS

The PainSMART-project is a research program with a collective suite of studies utilising mixed methods, centred around a randomised controlled trial (ClinicalTrials.gov NCT06187428). Subjects: Adults (18 years or older) seeking primary care for MSKP who are triaged and booked for an initial physiotherapy consultation at five primary care physiotherapy departments within the Swedish public healthcare regions of Östergötland and Jönköping. A total of 490 subjects will be randomised to receive one of two possible interventions.

INTERVENTIONS

Both groups will receive usual physiotherapy management for benign MSKP. The intervention group will also receive the PainSMART-strategy consisting of an educational film, reflection and reinforcement of the film's key messages prior to the initial physiotherapy consultation and a patient-practitioner discussion based on the film.

OUTCOME

The primary outcome is 1) between group mean change over time from baseline to 24 hours post initial physiotherapy consultation and baseline to 3 months regarding self-reported average pain intensity and pain self-efficacy. Secondary outcomes include similar measurements for MSKP illness perception, reassurance of benign nature, pain coping, physical activity, analgesic medication use, sick leave, healthcare use and direct healthcare costs. Physiotherapist and patient reported experience measures and qualitative evaluation of the effects of the PainSMART-strategy on communication at the initial physiotherapy consultation will also be explored.

DISCUSSION

This study will investigate potential added effects of PainSMART-strategy upon usual primary care physiotherapy for MSKP.

Adherence to neck and low back pain clinical practice guidelines based on clinical specialization: a survey of physical therapists

OBJECTIVE

To investigate physical therapist adherence to the Academy of Orthopaedic Physical Therapy's (AOPT) clinical practice guidelines (CPGs) for the management of neck and low back pain (LBP) and to compare adherence among varying clinical specializations.

DESIGN

Electronic cross-sectional survey.

METHODS

The survey was sent to 17,348 AOPT members and 7,000 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) members. Participants selected the best diagnosis and intervention(s) for six case vignettes based on the current AOPT CPGs for neck and LBP. Diagnostic and intervention adherence rates were reported as total percentages and delineated by the highest level of clinical specialization - fellowship training (PTFs), orthopedic residency training (PTRs), Board Certified Clinical Specialist in Orthopaedic Physical Therapy (PTSs), orthopedic background without clinical specialization (PTOs). Binary logistic regression analyses were performed to determine the effects of clinical specialization (PTFs, PTRs, or PTSs) compared to PTOs on the likelihood of guideline adherence for all six cases.

RESULTS

Of the 159 participants who responded to the survey, 152 were eligible and 145 completed demographic data. Participant responses declined as the survey progressed from 125 completing case one to 106 completing case six. The odds ratio from binary logistic regression analyses were not significant for any specialization in all six cases (OR = 0.16; 95% CI: 0.02, 1.11; p = 0.064).

CONCLUSIONS

The results of this manuscript demonstrated variable adherence rates across subgroups of patients with neck and LBP with no significant association between clinical specialization and adherence. Adherence to CPGs is dependent on the clinical presentation of various patient cohorts.

Provider kinematic strategies during the delivery of spinal manipulation and mobilization: a scoping review of the literature

BACKGROUND

Spinal manipulation (MAN) and mobilization (MOB) are biomechanically different yet both elicit pain reduction and increased range of motion. Previous investigations have focused on quantifying kinetics (e.g., applied forces) or, recipient kinematics (i.e., movements) during MAN and MOB. While these studies provide valuable information, they do not report on the strategies adopted by providers when performing the complex motor tasks of MAN and MOB. This review sought to synthesise the literature reporting on provider kinematics during the delivery of MAN and MOB.

METHODS

This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. MEDLINE (Ovid), PsychINFO, Cochrane Library, Web of Science, Embase, Scopus, PEDro, ICL and CINAHL databases were searched from inception to September 2023 for terms relating to provider kinematics during the delivery of MAN and MOB. Data were extracted and reported descriptively, including: general study characteristics, number and characteristics of individuals who delivered/received MAN and/or MOB, region treated, equipment used and kinematic parameters of the individual delivering the procedure.

RESULTS

Of 4,844 records identified, five (0.1%) fulfilled the eligibility criteria and were included in the analysis. Of these, provider kinematics were reported for the delivery of MAN in four (80%) and for the delivery of MOB in one (20%) article. Practitioners applied the procedure in all (100%) and students in one (20%) study. Spinal regions treated were: lumbar (n = 4), thoracic (n = 2) and cervical (n = 1). Data were reported heterogeneously but were most commonly captured using either video or motion capture equipment (n = 4, 80%). The direction of applied force was fully reported in one (20%) and only partially reported (one spinal region) in another study.

CONCLUSIONS

There are a small number of studies reporting heterogeneously on provider kinematics during the delivery of MAN and MOB. Clear reporting of the procedure from a biomechanical perspective and of the measurement equipment used could enable future meta-analysis of provider kinematic data, the use of provider kinematic data in the development of technique skills curricula and could feasibly be used to mitigate risk of injury for providers.

Validation of the OPTIMAL-Confidence Questionnaire in Patients with Chronic Low Back Pain

Background/Objectives: Low back pain is one of the most prevalent pathologies. Several studies relate its chronification to certain psycho-emotional characteristics, such as self-efficacy or the patient's lack of confidence in the ability to move. Determine the reliability and validity of the OPTIMAL-confidence scale in people with chronic low back pain and describe the confidence in the movement capacity of this population. Methods: Design: A validation study was designed to evaluate the psychometric properties of the OPTIMAL-Confidence Questionnaire in a population with chronic low back pain. A descriptive observational study in a population with chronic low back pain and a healthy population was designed to describe the confidence in the movement capacity of the population with chronic low back pain.

SETTINGS

Health centers of primary care from a region of northwestern Spain.

PARTICIPANTS

The final sample was 122 patients diagnosed with chronic low back pain. The sampling was completed with 30 additional healthy subjects.

INSTRUMENTS

OPTIMAL-confidence questionnaire, Numerical Pain Rating Scale, Chronic Pain Self-efficacy Scale, and ad hoc questionnaire to collect socio-demographic and clinical variables. Results: Cronbach's alpha for the OPTIMAL-confidence questionnaire was 0.91. The association of OPTIMAL-confidence with the self-efficacy, pain intensity, and movement ability scales was moderate and significant (p < 0.001). Regarding the low back pain population, significant differences were observed in confidence levels according to age and the need for walking aids (p < 0.009). The OPTIMAL-confidence questionnaire also showed significant discrimination between the low back pain group and the no back pain group (p < 0.001). The confidence interval was 95%. Conclusions: The population with low back pain shows less confidence in their ability to perform movements, compared to the general population. OPTIMAL is an instrument that can discriminate between patients who present chronic low back pain and those who do not.

Spinal Cord Stimulation for Low Back Pain: A Systematic Review

PURPOSE OF REVIEW

Chronic low back pain (LBP) is a prevalent and debilitating condition affecting millions worldwide. Among emerging interventions, spinal cord stimulation (SCS) has gained attention as a potential alternative for managing chronic LBP, particularly when alternative approaches fail to provide adequate relief.

RECENT FINDINGS

This systematic review focuses on both residual pain levels and ability to perform daily tasks after treatment with SCS. The present investigation includes a systematic search for studies from PubMed, Google Scholar, and Cochrane, and Embase. Sources were eligible for inclusion in the review if they were published from 2010 to present (May 1, 2024). 8 studies involving a total of 1,172 patients were evaluated. This systematic review demonstrated that SCS is superior to conventional medical management (CMM) for both short and long-term pain relief, functionality, psychological well-being, and opioid dependency. Furthermore, newer SCS approaches, such as high frequency (HF), differential target multiplexed (DTM), and multiphase SCS all demonstrated improved efficacy over traditional SCS for pain relief and functionality scores. Adverse event rates for all trials were low and represent the safety of SCS treatments. The present investigation provides insight into the capabilities of both traditional SCS and HF SCS, DTM SCS, and multiphase SCS as compared to baseline pain and functionality as well as conventional medical management (CMM). This review grants physicians a broader picture of the applicability of SCS, its safety profile, and the opportunities it offers for pain reduction and functionality over CMM.

Use of Intervention Mapping to Adapt a Psychologically Informed Physical Therapy Telerehabilitation Intervention for Latino Persons With Chronic Spine Pain

The need for culturally tailored pain care is well-recognized, yet few studies report how existing interventions can be adapted to the needs of culturally and linguistically diverse populations. This report describes a formative mixed-methods approach using intervention mapping-adapt and the expanded framework for reporting adaptations and modifications to evidence-based interventions to adapt and report modifications of an existing physical therapy intervention for Latino persons with chronic spine pain in Federally Qualified Health clinics in the southwestern United States. Mixed methods included literature reviews, patient surveys, an Adaptation Advisory Panel, and sequential case series with semistructured interviews. Six steps of intervention mapping-adapt guided the adaptation process and adaptations were prospectively documented with framework for reporting adaptations and modifications to evidence-based interventions. A needs assessment revealed an absence of culturally tailored physical therapy interventions for Latino persons with chronic spine pain in the United States. An intervention logic model and review of the sociocultural context guided the selection of essential interventions, determinants of behavior change, and outcomes. An existing cognitive behavioral-based physical therapy telerehabilitation intervention was selected for adaptation based on accessibility and strong congruency with the logic model. An Adaptation Advisory Panel planned and evaluated iterative adaptations of the cognitive behavioral-based physical therapy intervention content, activities, delivery, materials, and design. The adapted Goal-Oriented Activity for Latino persons with Spine pain intervention aimed to reduce pain intensity and disability through patient-centered goal setting in physical and cognitive treatment domains. Sequential case series supported feasibility and acceptability of the adapted intervention in the target population. PERSPECTIVE: We describe adaptation and reporting of an evidence-based physical therapy intervention for a culturally and linguistically diverse population. Greater rigor and transparency using tools such as intervention mapping-adapt and framework for reporting adaptations and modifications to evidence-based interventions will accelerate efforts to reduce ethnic and racial disparities in pain rehabilitation.

The Oswestry Disability Index is not a good measure for low back pain in adolescents: A Rasch analysis of data from 200 people

OBJECTIVE

To evaluate the psychometric properties of the modified Oswestry Disability Index in adolescents with low back pain through Rasch analysis.

DESIGN

This is a psychometric study.

SETTING

Physical therapy clinics of a large pediatric hospital in Columbus, Ohio (United States).

SUBJECTS

Two hundred adolescent patients with low back pain (112 female, 15.4 ± 1.9 years old).

MAIN MEASURE

The modified Oswestry Disability Index.

RESULTS

The mean modified Oswestry Disability Index score was 17.1 ± 12.1, with scores ranging from 0 to 56 on the 100-point scale. The Rasch person reliability for the Oswestry Disability Index was 0.70, representing minimal acceptable person reliability. The Oswestry Disability Index demonstrated poor item spacing, hierarchy, and targeting of the adolescents' disability level (>1 logit between person mean and item mean). A significant misfit was observed in three of 10 items. There were significant issues with the functioning of responses on all items of the Oswestry Disability Index. Principal component analysis of residuals revealed a ratio of 5.3:1, demonstrating acceptable unidimensionality.

CONCLUSION

Due to multiple psychometric issues, the Oswestry Disability should not be used to assess disability in adolescents with low back pain. The Oswestry Disability Index significantly mistargets adolescent ability and only provides an acceptable assessment of the most disabled adolescents.

Management of Lumbar Disc Herniation With Nerve Compression in a 21-Year-Old Male: A Case Report Exploring Multifactorial Causes of Disc Herniation

Lumbar disc herniation (LDH) is a major cause of low back pain traditionally associated with age-related degenerative changes of intervertebral discs in adults aged 30-50 years. Symptoms of LDH can include pain, sensory disturbances, or motor deficits depending on the degree of nerve root compression. This case report highlights a 21-year-old male college student with LDH and nerve root compression, complicated by a prior anterior cruciate ligament (ACL) injury and a sedentary lifestyle. Magnetic resonance imaging (MRI) findings revealed a left L4 nerve root compression and a central-to-right paracentral herniation affecting the right S1 nerve root. The assessment demonstrated significant pain and reduced range of motion (ROM) in hip flexion and extension. Physical therapy utilizing a multimodal approach emphasizing spinal stabilization, postural correction, and mobility exercises was implemented to enhance the patient's function and recovery process. Over the course of treatment, notable improvements in ROM and pain levels were observed. Treatment successfully culminated in minimal pain by the patient's final session. After physical therapy had concluded, and our patient resumed regular activities, he was able to achieve complete pain remission in approximately three months with ROM also returning to baseline. This case report underscores the multifactorial contributors to LDH in young adults, emphasizing the importance of a comprehensive approach to rehabilitation in managing spinal injuries for optimal outcomes.

Nonpharmacological Spine Pain Management in Clinical Practice Guidelines: A Systematic Review Using AGREE II and AGREE-REX Tools

OBJECTIVE: To summarize the content and critically appraise the quality and applicability of recent clinical practice guidelines (CPGs) for nonpharmacological, nonsurgical management of spine pain. DESIGN: Systematic review of CPGs. LITERATURE SEARCH: Six databases and seven guideline clearinghouses. STUDY SELECTION CRITERIA: Included de novo CPGs for nonpharmacological, nonsurgical management of spine pain designed for any primary health care providers, published in English, Arabic, French, or traditional Chinese within the past 12 years. DATA SYNTHESIS: Five reviewers independently appraised the guidelines using AGREE II and AGREE-REX. Interrater agreements were calculated for each domain and the total score of these tools using the intraclass correlation coefficient (2, 1) with absolute agreement. RESULTS: We included 30 CPGs, primarily (90%) developed in Western countries, which contained 404 recommendations. High-quality CPGs consistently recommended exercise therapy and multimodal care, encompassing a combination of exercises, mobilization/manipulation, education, alternative medicine, and cognitive-behavioral treatments. Generally, CPGs did not recommend assistive (eg, corsets and orthosis) devices or electro/thermotherapies (eg, therapeutic ultrasound and transcutaneous electrical nerve stimulation). Approximately half of the CPGs demonstrated good methodological quality according to AGREE II, whereas the rest were of poor quality. On the AGREE-REX assessment, one third of the recommendations were of excellent quality. CONCLUSION: Although recent guidelines frequently recommended exercise therapy and multimodal care for the management of spine pain, their recommendations often overlooked demographics and comorbidities. Despite methodological improvements, most CPGs lacked simple clinical applicability and considerations of knowledge users' values. J Orthop Sports Phys Ther 2025;55(1):1-14. Epub 4 November 2024. doi:10.2519/jospt.2024.12729.

Inequities in Physical Therapy Receipt of US Service Members and Veterans With Low Back Pain

OBJECTIVE

To investigate inequities in time to physical therapy (PT) for patients with low back pain (LBP).

DESIGN

Retrospective observational study using data from the Department of Defense and Veterans Health Administration clinical and administrative data repositories derived from medical records, claims, and enrolment data.

SETTING

Military Health System, Veterans Health Administration, and civilian health care facilities.

PARTICIPANTS

Active duty service members, veterans, and retirees seeking health care for LBP between January 2017 and December 2020, with no LBP diagnoses for at least 1 year prior (N=1,252,959).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Time to-outpatient PT evaluation within 13 weeks of LBP diagnosis.

RESULTS

Approximately 9.4% of included patients received an outpatient PT evaluation from a physical therapist within 13 weeks of diagnosis. In a piecewise exponential additive model, many covariates were time-varying, such that the probability of PT receipt varied throughout the 13-week period. Black, Latinx, and American Indian and Alaskan Native patients had lower probabilities of PT receipt than White patients from 1 to 3-6 weeks after index diagnosis. At 5 and 7 weeks, Black and Latinx patients, respectively, were more likely to receive PT than White patients, which continued until the end of the observation period. Patients assigned female relative to patients assigned male relative had a higher probability of initiating PT across the entire observation window, as did active duty service members, relative to retired service members and veterans.

CONCLUSIONS

Inequities in the timing and receipt of PT exist in the US Military Health System and Veterans Health Administration by race and ethnicity, assigned sex, and beneficiary group. Standardizing referral and practice patterns, improving accessibility of PT services, and encouraging health-seeking behavior may help alleviate the inequities in initiating PT.

Is Hip Muscle Flexibility Associated with Low Back Pain Among First-Year Undergraduate Students?

Background/Objectives: Hip muscle lengthening is commonly associated with the normal function of the lumbar spine and lower extremities. Some evidence correlates hamstring and iliopsoas tightness with low back pain (LBP). Undergraduates are more prone to LBP as they are involved in prolonged sitting and poor posture. This study aims to assess the impact of hip muscle lengthening on LBP. Methods: This article involves a descriptive study of 70 students who were recruited from Zefat Academic College. Measurement of hamstrings and iliopsoas muscle lengthening, as well as a constructive questionnaire, were used. Results: The majority of participants (80% for hamstrings and 96% for iliopsoas) manifested normal muscle lengthening. Muscle flexibility was significantly higher among females. Logistic regression analyses revealed that hamstring lengthening (right) and stress-related study are significantly associated with LBP. Conclusions: The current study indicates that muscle length is female-dependent and right-left muscle length is symmetrical. Increased hamstring length could be related to LBP.

Lumbopelvic rhythm analysis by quartiles: Identification of differences in lumbar and pelvic contribution during trunk flexion and extension in subjects with low back pain of different origin. A case-control study

Low back pain (LBP) can alters spinal kinematics. However, for adequate clinical care, a better understanding of lumbopelvic biomechanical behaviour according to the type of LBP is required. Our objectives were to identify differences in lumbopelvic rhythm (LPR) between subjects with acute low back pain (aLBP), axial spondyloarthritis (axSpA) and healthy subjects. As well as to identify correlations between LPR and sociodemographic and clinical data. In each group of 39 subjects, LPR total and by quartiles (Q) and metrological and clinical data were evaluated. No differences were found in relation to total flexion and LPR extension. However, study by Q showed less movement in aLBP compared to axSpA and healthy subjects at the Lumbar level in Q2 (p = 0.001), Pelvis in Q3 and Q4 and Trunk in Q3 (p=<0.001). In Q4 the aLBP moved the Trunk less than axSpA exclusively [-3,64°(95 % confidence interval - 6.53,-0.74), p = 0.011]. For the extension movement, the Pelvic motion of Q2 was lower for the aLBP group compared to axSpA group [-3,11°(-6.00,-0.22), p = 0.030], and Trunk motion of Q2 and Q3 (p = 0.001, p = 0.007, respectively), and Lumbar mobility of Q3 were also lower compared to axSpA and control groups (p = 0.031). Specific correlations were found for each group. aLBP with BMI, axSpA with metrology and Healthy subjects with age. Subjects with aLBP showed less lumbar, pelvic or trunk movement in Q2 and Q3 of trunk flexion and extension movements than axSpA and controls. RPL and its interrelationships with sociodemographic and clinical variables depend on the lumbar condition.

The Development of an Opioid Misuse Training Program for Physical Therapists: A Learning Community Approach

INTRODUCTION

Musculoskeletal pain and opioid misuse frequently co-occur.

REVIEW OF THE LITERATURE

The US Preventive Services Task Force calls for all health care providers to be trained to screen for misuse and/or opioid use disorder. The purpose of this study was to develop and implement an opioid misuse training program that could be used by physical therapists.

SUBJECTS

Thirteen practicing physical therapists were invited to participate in a curriculum development project.

METHODS

Using the Curriculum Framework, a collaborative learning approach was used to develop an opioid misuse training program and training manual for physical therapists. Four training sessions were provided virtually every 2 weeks. Topics included an introduction to the opioid crisis, screening, assessing, and communicating with patients and with the health care team about opioid misuse. Each didactic session was followed by a participant feedback session where participants provided recommendations on improving the training content and their impressions on the barriers and facilitators to incorporating the training into practice. A companion training manual was created and sent to participants for comment. Participants were asked over email to describe whether and how they incorporated training materials into clinical practice during the training curriculum.

RESULTS

All participants attended sessions 1-3. Twelve (92.3%) attended the fourth session. Based on the participants' feedback, training sessions were edited, and a companion training manual was finalized and distributed to each participant. After the fourth session, 9 participants (69.2%) reported using what they learned in the training. During the participant feedback sessions, participants regarded the training as important. Some participants expressed barriers to discussing opioids with patients and concerns about whether the training was within physical therapists' scope of practice.

DISCUSSION AND CONCLUSION

An iteratively developed training program for physical therapists to address opioid misuse was acceptable, feasible, and provided immediate practice change by most participants.

Associations of Co-Occurring Chronic Conditions With Use of Rehabilitation Services in Older Adults With Back Pain: A Population-Based Cohort Study

OBJECTIVE

The objective was to examine the associations of number and type of chronic conditions with the use of rehabilitation services among older adults with bothersome back pain.

METHODS

We conducted a cohort study using the National Health and Aging Trends Study, a longitudinal survey of Medicare beneficiaries ≥65 years. We included community-dwelling older adults with bothersome back pain in 2015. We assessed 12 self-reported chronic conditions, including arthritis, depression, and anxiety. We used 2016 data to ascertain self-reported use of any rehabilitation services in the prior year. We used weighted, logistic regression to examine the association of conditions with rehabilitation use.

RESULTS

The sample size was 2443. A majority were age ≥75 years (59%); female (62%); and White, non-Hispanic (71%). The median number of chronic conditions was 3 (interquartile range, 2-4). Arthritis was the most common chronic condition (73%); 14% had anxiety; and 16% had depression. For every additional chronic condition, adjusted odds of any rehabilitation use increased 21% (Odds Ratio = 1.21, 95% CI = 1.11-1.31). Those with ≥4 chronic conditions had 2.13 times higher odds (95% CI = 1.36-3.34) of any rehabilitation use in the next year versus those with 0-1 condition. Participants with arthritis had 1.96 times higher odds (95% CI = 1.41-2.72) of any rehabilitation use versus those without arthritis. Anxiety and depression were not significantly associated with rehabilitation use.

CONCLUSIONS

Among older adults with back pain, a greater number of chronic conditions and arthritis were associated with higher use of rehabilitation services. Those with anxiety or depression had no difference in their use of rehabilitation care versus those without these conditions.

IMPACT

This pattern suggests appropriate use of rehabilitation for patients with back pain and multiple chronic conditions based on greater need, but there may be potential underuse for those with back pain and psychological conditions.

Comparison of Cognitive Functions Between Individuals With Chronic Low Back Pain With High and Low Pain Catastrophizing and Pain-free Controls: A Cross-sectional Study

OBJECTIVES

Researchers suggested that the interruptive effects of chronic pain on cognitive functions may be modulated by the level of pain catastrophizing (PC). However, in individuals with chronic low back pain (CLBP), domains of cognitive function that may be affected by the level of PC remain largely unclear. Therefore, this study aimed to compare cognitive functions between individuals with CLBP with high and low PC and pain-free controls.

MATERIALS AND METHODS

This cross-sectional study examined cognitive functions of 42 individuals with CLBP and 21 pain-free controls. The PC scale was used to stratify participants with CLBP into high and low PC. Participants performed 5 cognitive tests from the Cambridge Neuropsychological Test Automated Battery, namely 5-choice reaction time, rapid visual processing, spatial working memory, attention switching task, and stop signal task.

RESULTS

The statistical analyses revealed that compared with individuals with CLBP with low PC and pain-free controls, individuals with high PC demonstrated greater values of the between errors ( P =0.01), reaction latency ( P <0.001), and stop signal reaction time variables ( P =0.004, 0.003, respectively) but lower values of probability of hit ( P =0.02, 0.01, respectively), A' ( P =0.01, <0.001, respectively), and percent correct trials variables ( P =0.002, <0.001, respectively).

DISCUSSION

The results of the current study showed deficits in sustained attention, working memory, cognitive flexibility, and inhibitory control in individuals with CLBP with high PC. From a clinical perspective, therapeutic interventions targeting PC should be considered to decrease catastrophic thinking about pain in individuals with CLBP. Additional research is warranted to explore cognitive functioning as an outcome of these interventions in individuals with CLBP.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Lower cross syndrome: specific treatment protocol versus generalized treatment protocol. A randomized single-blinded trial

INTRODUCTION

Lower crossed syndrome (LCS) is a biomechanical muscle imbalance causing low back pain.

Effectiveness of gluteal control training in chronic low back pain patients with functional leg length inequality

Chronic low back pain (LBP) is a common musculoskeletal disorder and is often accompanied by functional leg length inequality (FLLI). However, little was known about the effects of gluteal muscle control training in patients with LBP and FLLI. This study was designed to investigate the effects of gluteal control training in patients with LBP and FLLI. This is a double-blinded, randomized controlled study design. Forty-eight LBP patients with FLLI were randomized to the gluteal control training (GT) (47.58 ± 9.42 years) or the regular training (RT) (47.38 ± 11.31 years) group and received allocated training for six weeks. The outcome measures were pelvic inclination (PI), ilium anterior tilt difference (IATD), FLLI, visual analogue scale (VAS), patient specific-functional scale (PSFS), Oswestry disability index (ODI), hip control ability, global rating of change scale (GRoC), and lower extremity strength and flexibility. The intervention effects were compared using two-way repeated measures analysis of variance and chi-square tests with α = 0.05. The results indicated that the GT group showed greater improvement (P < 0.01) in PI (1.03 ± 0.38∘ vs. 1.57 ± 0.51∘), IATD (0.68 ± 0.66∘ vs. 2.31 ± 0.66∘), FLLI (0.3 ± 0.22 vs. 0.59 ± 0.13 cm), VAS (1.41 ± 1.32 vs. 3.38 ± 1.51), hip control ability (2.20 ± 0.45 vs. 0.89 ± 0.74), GRoC at 3rd and 6th week as compared to the RT group. Hip strength and flexibility also improved more in the GT group (P < 0.05). In conclusion, gluteal control training was more effective in improving low back pain and dysfunctions, and should be integrated in the management plan in patients with LBP and FLLI.

Duration, Cost, and Escalation of Care Events for Physical Therapy Management of Low Back Pain in Service Members With Limb Loss

INTRODUCTION

Physical therapy (PT) is recommended as a primary treatment for low back pain (LBP), a common and impactful musculoskeletal condition after limb loss. The purpose of this brief report is to report the duration and cost of PT care, and subsequent escalation of care events, for LBP in service members with and without limb loss.

MATERIALS AND METHODS

This was a retrospective cohort, descriptive study. Service members with and without limb loss (matched) who received PT for LBP at a military treatment facility from 2015 to 2017 were included. Duration of PT care, number of PT visits, and escalation of care events 1 year after PT were extracted from medical records. Escalation of care events was identified as epidural steroid injections, referrals to specialists (e.g., orthopedists, spine surgeons, and pain management), and LBP-related hospitalizations.LBP-related PT encounters were queried; duration of care, number of visits, and cost of care were quantified. Escalation of care events, including opioid prescription, epidural steroid injections, specialty referrals, and hospitalizations, were identified up to 1 year after PT care.

RESULTS

The average course of PT care for LBP was 12.9 more visits, 48.7 days longer, and $764.50 more expensive in service members with limb loss (n = 16) vs. those without limb loss (n = 48). Higher rates of opioid prescriptions and specialty referrals were observed in service members with limb loss.

CONCLUSIONS

This study suggests that service members with limb loss and LBP received higher quantities and longer durations of PT than those without limb loss, yielding a nearly 4 times higher cost of PT.

The Influence of Active, Passive, and Manual Therapy Interventions on Escalation of Health Care Events After Physical Therapist Care in Veterans With Low Back Pain

OBJECTIVE

The objective of this study was to examine the associations between active, passive, and manual therapy interventions with the escalation-of-care events following physical therapist care for veterans with low back pain (LBP).

METHODS

A retrospective cohort study was conducted in 3618 veterans who received physical therapist care for LBP between January 1, 2015 and January 1, 2018. The Department of Veterans Affairs (VA) Corporate Data Warehouse was utilized to identify LBP-related physical therapist visits and procedures, as well as opioid prescription and non-physical therapy clinic encounters. The association between physical therapist interventions with 1-year escalation-of-care events were assessed using adjusted odds ratios from logistic regression.

RESULTS

Nearly all veterans (98%) received active interventions, but only a minority (31%) received manual therapy. In the 1-year follow-up period, the odds of receiving an opioid prescription were 30% lower for those who received manual therapy in addition to active interventions, as compared with patients who received only active interventions. Moreover, the odds of receiving primary care, specialty care, and diagnostic testing were 30% to 130% higher for patients who received electrical stimulation or more than 1 passive intervention in addition to active treatments, as compared with patients who received only active interventions.

CONCLUSION

The use of manual therapy along with active interventions was associated with reduced prescription of opioids, while utilization of specific passive interventions such as electrical stimulation or multiple modalities in conjunction with active interventions resulted in increased escalation-of-care events.

IMPACT

The use of active interventions, which is supported by most clinical practice guidelines, was the cornerstone of physical therapist care for veterans with LBP. However, the use of clinical practice guideline-recommended manual therapy interventions was low but associated with reduced opioid prescriptions. The use of 2 or more different passive interventions along with active interventions was common (34%) and associated with less-than-optimal escalation-of-care outcomes.

Effects of Fu's subcutaneous needling on clinical efficacy and psychological cognitive characteristics in patients with chronic non-specific low back pain: A randomized controlled trial

BACKGROUND AND PURPOSE

Low back pain (LBP) is a major global public health problem. Evidence shows that LBP is also related to cognitive, psychological, and lifestyle factors. Fu's subcutaneous needling (FSN) has been used for the treatment of musculoskeletal problems for many years. This prospective randomized controlled trial aimed to evaluate the clinical efficacy and fear avoidance beliefs of FSN in the treatment of patients with chronic non-specific LBP.

MATERIAL AND METHODS

Ninety participants with chronic non-specific LBP were randomly divided into the FSN and the traditional acupuncture (TA) groups (n = 45) and received either FSN or TA treatment for three consecutive days from December 2021 to March 2023. The primary outcome was pain intensity measured by the visual analogue scale (VAS). Secondary outcomes were trunk extensor endurance (TEE), lumbar range of motion (ROM), and the Fear Avoidance Beliefs Questionnaire (FABQ). Outcome measurements were made before the first treatment and after each treatment. Follow-up assessments of VAS and FABQ scores were conducted one month after treatment.

RESULTS

The FSN group had significantly lower VAS and FABQ scores at each time point after intervention compared to the TA group (P < 0.01). The scores of TEE and lumbar ROM were higher in the FSN group than those in the TA group (P < 0.01). Repeated measures analysis of variance (ANOVA) showed significant time effects, group effects, and interaction effects for VAS, TEE, lumbar ROM, and FABQ in both groups (P < 0.01). One month after treatment, the FSN group had significantly lower VAS and FABQ scores compared to the TA group (P < 0.05).

CONCLUSION

This study suggested that FSN was superior to TA in terms of clinical efficacy and fear-avoidance beliefs in the treatment of chronic non-specific LBP. FSN could be used as an effective clinical treatment.

Hip capsular pattern and chronic non-specific low back pain -A case controlled prospective study

BACKGROUND

Individuals with chronic nonspecific low back pain (CNLBP) presents with altered lumbosacral biomechanics, potentially stemming from compromised hip joint mobility. The objective of our study was to assess hip range of motion (ROM) and hamstring flexibility in individuals with CNLBP to ascertain the presence of a hip capsular pattern in relation to age-matched controls.

METHODS

This study was conducted at a tertiary hospital between July 2017 and September 2018, with approval from the institutional review board (JIP/IEC/2017/0044). Inclusion criteria encompassed axial or non-radiating pain primarily in the back for more than 3 months with no definitive pathology. A group of individuals with CNLBP (n = 27) and a control group (n = 30) of age-matched healthy volunteers were included. The observers were blinded to grouping. Bilateral hip range of motion and hamstring flexibility were measured.

RESULTS

Individuals with CNLBP exhibited a significant mean reduction in hip adduction (9.68 & 8.8o) and internal rotation (7.19 & 7.09°) of the right and left hips, respectively. Additionally, there was a mean increase in flexion (7.68 & 7.71°), extension (6.99 & 8.64°), abduction (7.08 & 8.02°), and external rotation (20.4 & 20.1°) of the right and left hips, respectively, compared to controls (p < 0.01). Notably, hamstring flexibility did not show a significant difference (P > 0.05).

CONCLUSION

Based on this study, it is plausible that individuals with CNLBP may exhibit a hip capsular pattern (FABER), with the exception of flexion, when compared to age-matched normal individuals. Also, it was also noted that hamstring tightness did not accompany CNLBP.

Immediate effects of thoracic mobilization versus soft tissue release on trunk motion, pain, and lumbar muscle activity in patients with chronic low back pain

INTRODUCTION

Thoracic mobilization and tissue release are common manual techniques in clinical practice. However, the relative effects of these two treatments on chronic low back pain (CLBP) have not yet been explored. Thus, this study aimed to investigate and compare the immediate effects of thoracic mobilization with those of soft tissue release on trunk movement, pain sensation, and muscle activity in patients with CLBP.

METHODS

28 participants were randomly assigned to two intervention groups. The mobilization group received mobilization treatment at the hypomobile joints of the trunk segment, while the soft tissue release group received thoracolumbar fascia release and massage in the lumbar region. The trunk range of motion (ROM), tissue hardness, pressure pain threshold (PPT), and erector spinae activity during light-weight lifting tasks were measured before and immediately after both interventions.

FINDINGS

All measured outcomes in both groups improved after intervention (p < 0.05). The mobilization technique significantly improved side bending and rotation, PPT, and tissue hardness compared to soft tissue release. However, lumbar muscle activation reduced to a greater extent in the soft-tissue release group.

CONCLUSION

Both techniques improved trunk ROM and PPT and reduced tissue hardness and muscle activation. Therefore, both these techniques are recommended for patients with CLBP.

TRIAL REGISTRATION

ISRCTN75190733.

Coverage of Physical Therapy Assessments in the Observational Medical Outcomes Partnership Common Data Model

BACKGROUND

 High-value care aims to enhance meaningful patient outcomes while reducing costs and is accelerated by curating data across health care systems through common data models (CDMs), such as Observational Medical Outcomes Partnership (OMOP). Meaningful patient outcomes, such as physical function, must be included in these CDMs. However, the extent to which physical therapy assessments are covered in the OMOP CDM is unclear.

OBJECTIVE

This study aimed to examine the extent to which physical therapy assessments used in neurologic and orthopaedic conditions are in the OMOP CDM.

METHODS

 After identifying assessments, two reviewer teams independently mapped the neurologic and orthopaedic assessments into the OMOP CDM. Agreement within the reviewer team was assessed by the number of assessments mapped by both reviewers, one reviewer but not the other, or neither reviewer. The reviewer teams then reconciled disagreements, after which agreement and the average number of concept ID numbers per assessment were assessed.

RESULTS

 Of the 81 neurologic assessments, 48.1% (39/81) were initially mapped by both reviewers, 9.9% (8/81) were mapped by one reviewer but not the other, and 42% (34/81) were unmapped. After reconciliation, 46.9% (38/81) were mapped by both reviewers and 53.1% (43/81) were unmapped. Of the 79 orthopaedic assessments, 46.8% (37/79) were initially mapped by both reviewers, 12.7% (10/79) were mapped by one reviewer but not the other, and 48.1% (38/79) were unmapped. After reconciliation, 48.1% (38/79) were mapped by both reviewers and 51.9% (41/79) were unmapped. Most assessments that were mapped had more than one concept ID number (2.2 ± 1.3 and 4.3 ± 4.4 concept IDs per neurologic and orthopaedic assessment, respectively).

CONCLUSION

 The OMOP CDM includes some physical therapy assessments recommended for use in neurologic and orthopaedic conditions but many have multiple concept IDs. Including more functional assessments in the OMOP CDM and creating guidelines for mapping would improve our ability to include functional data in large datasets.

Sling Exercise in the Management of Chronic Low Back Pain: A Systematic Review and Meta-Analysis

ABSTRACT

Drummond, C, Lebedeva, V, Kirker, K, and Masaracchio, M. Sling exercise in the management of chronic low back pain: A systematic review and meta-analysis. J Strength Cond Res 38(10): 1822-1833, 2024-The purpose of this systematic review is to assess the effectiveness of sling exercise therapy (SET) in individuals with chronic low back pain (LBP). Eligible studies were randomized clinical trials or prospective cohort studies published in the English language that assessed SET on measures of pain, disability, or muscle attributes in chronic LBP. The search identified 1,204 studies, with 12 studies meeting the inclusion criteria. The average score was 7.3 on the Cochrane Risk of Bias Criteria. Meta-analysis comparing SET with general exercise revealed a nonsignificant effect for pain (mean difference [MD] 0.14; 95% confidence interval [CI]: -0.58, 0.87). Meta-analysis comparing SET with motor control training/lumbar stabilization revealed a significant effect favoring SET for pain (MD -4.13; 95% CI: -7.82 to -0.45) and disability (MD -3.19; 95% CI: -4.63 to -1.76). Meta-analysis comparing SET with no treatment revealed a significant effect favoring SET for pain (MD -1.05; 95% CI: -2.82 to -0.71). Meta-analysis comparing SET plus modalities with modalities revealed a significant effect favoring the SET plus modalities group for pain (MD -1.19; 95% CI: -1.48 to -0.89) and a nonsignificant effect for disability (MD -6.67; 95% CI: -17.25 to 3.92). Sling exercise therapy was more effective than all comparisons for various muscle attributes. The overall level of evidence ranged from very low to moderate. Sling exercise therapy is effective in reducing pain, disability, and improving core muscle activation, strength, thickness, and onset in patients with chronic LBP. Because SET demonstrated comparable outcomes with common active interventions, it provides an opportunity to implement pain-free exercises based on the patient's initial functional level early in the plan of care.

Development of prediction model for risks of musculoskeletal chronic lumbopelvic pain in Indian women

Chronic lumbopelvic pain (CLPP) and its associated disabilities significantly affect women's social, professional, and personal lives. However, the specific factors contributing to CLPP in women remain unclear. To address this gap, this prospective cross-sectional study aims to identify the risk factors predicting CLPP in women and develop a prediction model that can predict CLPP in women. The study was conducted across Delhi, India, where free health camps were held, and 2400 women were assessed. Among the assessed individuals, the study revealed a high prevalence rate of CLPP among Indian women, standing at 70.4%. Seven risk factors namely, hamstring muscle tightness (> 20° on passive knee extension test), increased lumbar lordosis (> 11.5 cm of the lumbar lordotic index), reduced hip flexibility (> 15 cm on bent knee fallout test), altered foot posture (≥ 20 on foot posture index score), increased perception of psychological stress (> 25 on cohen's perceived stress scale-10 score), reduced physical activity level (< 475 metabolic/minute on international physical activity questionnaire) and reduced performance of transversus abdominis muscle (≤ 5 on deep muscle contraction scale score) strongly predict the risks of CLPP in women. Identifying these risk factors is crucial for effectively preventing and managing CLPP symptoms, especially considering its high prevalence among Indian women. Health professionals should prioritize raising awareness about CLPP and its causative factors, as well as implementing strategies for early detection and intervention.

Association between movement speed and instability catch kinematics and the differences between individuals with and without chronic low back pain

Studies reported the existence of instability catch (IC) during trunk flexion in patients with chronic low back pain (CLBP). However, different movement speeds can cause different neuromuscular demands resulting in altered kinematic patterns. In addition, kinematic characterization corresponding to clinical observation of IC is still limited. Therefore, this study aimed to determine (1) the association between movement speed and kinematic parameters representing IC during trunk flexion and (2) the differences in kinematic parameters between individuals with and without CLBP. Fifteen no low back pain (NoLBP) and 15 CLBP individuals were recruited. Inertial measurement units (IMU) were attached to T3, L1, and S2 spinous processes. Participants performed active trunk flexion while IMU data were simultaneously collected. Total trunk, lumbar, and pelvic mean angular velocity (T_MV, L_MV, and P_MV), as well as number of zero-crossings, peak-to-peak, and area of sudden deceleration and acceleration (Num, P2P, and Area), were derived. Pearson's correlation tests were used to determine the association between T_MV and L_MV, P_MV, Num, P2P, and Area. An ANCOVA was performed to determine the difference in kinematic parameters between groups using movement speed as a covariate. Significant associations (P < 0.05) were found between movement speed and other kinematic parameters, except for Area. Results showed that L_MV significantly differed from the P_MV (P = 0.002) in the CLBP group, while a significant between-group difference (P = 0.037) was found in the P_MV. Additionally, significant between-group differences (P < 0.05) in P2P and Area were observed. The associations between movement speed and kinematic parameters suggest that movement speed changes can alter kinematic patterns. Therefore, clinicians may challenge lumbopelvic neuromuscular control by modifying movement speed to elicit greater change in kinematic patterns. In addition, the NoLBP group used shared lumbar and pelvic contributions, while the CLBP group used less pelvic contribution. Finally, P2P and Area appeared to offer the greatest sensitivity to differentiate between the groups. Overall, these findings may enhance the understanding of the mechanism underlying IC in CLBP.

The Effectiveness of Instruction on Lumbar Spine Thrust Joint Manipulation Task Performance

INTRODUCTION

Uncertainty exists regarding the best method for teaching thrust joint manipulation (TJM) to student physical therapists. The purpose of this study was to compare the effectiveness of Peyton's 4-step (P4) approach with the "see one, do one" (S1D1) approach for teaching students to perform a lumbar spine TJM task in an academic setting. Secondary objectives were to compare the effects of each instructional approach on students' attitudes and beliefs toward spinal TJM and on their motivation to learn to perform lumbar spine TJM.

REVIEW OF LITERATURE

The S1D1 approach is used in the health care professions for teaching clinical tasks to students. It is unclear whether the P4 approach may better prepare students to practice TJM.

SUBJECTS

Student physical therapists.

METHODS

Using a factorial quasi-experimental design, an equal number of students were assigned to a P4 or S1D1 instruction group for the TJM task. Students' performance accuracy, time, and outcome performing TJM in an academic setting were measured. Paper surveys were used to collect data about students' attitudes and beliefs toward spinal TJM and their motivation to learn TJM. A generalized estimating equations approach was used for data analysis.

RESULTS

Fifty-eight students (29 per group) completed the study. There was an interaction between the instruction group and time on task performance accuracy favoring the P4 approach (P = .03). There was no interaction between the instruction group and task performance time, task performance outcome, attitudes and beliefs toward spinal TJM, or motivation to learn TJM (all P > .19).

DISCUSSION AND CONCLUSION

The P4 approach more effectively improved student accuracy when performing the TJM task in an academic setting than the S1D1 approach. However, no differences between instruction were found for performance time or outcome. Students reported a favorable perception of learning lumbar spine TJM. These preliminary results suggest that instructors may use the P4 approach to improve students' TJM procedural knowledge before task practice. However, limitations of the study may affect the internal validity and generalizability of results.

Standardized screening of cognitive and affective tendencies in persons with low back pain: A knowledge translation project

BACKGROUND

The use of screening questionnaires (SQ) to evaluate affective or cognitive tendencies (CAT) in persons with low back pain (LBP) is recommended by clinical practice guidelines (CPG) yet few physical therapists (PTs) have adopted these recommendations.

OBJECTIVE

To develop and implement a tailored knowledge translation (KT) intervention in an outpatient rehabilitation practice to facilitate the uptake of SQ for CAT in persons with LBP.

METHODS

In a mixed-methods study, using the knowledge to action framework, PTs (n = 12) collaborated with research clinicians to improve the use of three SQ: 1) Primary Care Evaluation of Mental Disorders for Depressive Symptoms; 2) Fear-Avoidance Beliefs Questionnaire; and 3) Pain Catastrophizing Scale. Success of the intervention was measured through questionnaires, focus groups and chart audit.

RESULTS

A multimodal intervention to overcome specific identified barriers (i.e. time, forgetfulness, and lack of knowledge) was implemented. There was a 10% increase in the use of at least one SQ. PTs reported increased knowledge and use of the SQ but reported time and lack of confidence as barriers to implementation.

CONCLUSION

It was concluded that SQ for CAT can be successfully implemented; however, PTs felt unprepared to use the screening results to evaluate persons with CAT and more extensive training is recommended to change this practice pattern.

Physiotherapists' attitudes and beliefs in the management of low back pain: Protocol for a systematic review

BACKGROUND

Low back pain (LBP) poses a significant global health burden where a biopsychosocial model of care has been recommended. Physiotherapists (PTs) play a crucial role in LBP management; however, their attitudes and beliefs towards LBP were not reviewed in detail.

OBJECTIVE

This systematic review aims to summarise the attitudes and beliefs of PTs towards LBP and the factors influencing them.

METHODS

The review protocol and methods adhere to the PRISMA-P and Meta Analyses and Systematic Reviews for Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search of PubMed, Scopus, CINAHL, Web of Science, PEDro and Ovid databases will be conducted to search for cross-sectional studies evaluating PTs' attitudes and beliefs towards LBP. Two reviewers will independently screen the articles, conduct data extraction and assess methodological quality using the Joanna Briggs Institute's critical appraisal tool for prevalence studies. Data synthesis will involve a narrative synthesis of study characteristics, attitudes, beliefs, and methodological quality. If feasible, a meta-analysis will be performed to quantify the pooled effects.

CONCLUSION

Despite the emphasis on biopsychosocial approaches for managing LBP, the adoption of such approaches in physiotherapy practice is still suboptimal, with attitudes and beliefs of PTs being considered an important factor influencing treatment practices. Our review will summarise the literature on attitudes and beliefs of PTs towards LBP. Such knowledge would inform the need for development of additional interventions addressing the attitudes and beliefs that would eventually enhance the update of the biopsychosocial model of care in physiotherapy management of LBP.

Slit3 by PTH-Induced Osteoblast Secretion Repels Sensory Innervation in Spine Porous Endplates to Relieve Low Back Pain

During aging, the spine undergoes degenerative changes, particularly with vertebral endplate bone expansion and sclerosis, that is associated with nonspecific low back pain (LBP). We reported that parathyroid hormone (PTH) treatment could reduce vertebral endplate sclerosis and improve pain behaviors in aging, SM/J and young lumbar spine instability (LSI) mice. Aberrant innervation noted in the vertebral body and endplate during spinal degeneration was reduced with PTH treatment in aging and LSI mice as quantified by PGP9.5+ and CGRP+ nerve fibers, as well as CGRP expression in dorsal root ganglia (DRG). The neuronal repulsion factor Slit3 significantly increased in response to PTH treatment mediated by transcriptional factor FoxA2. PTH type1 receptor (PPR) and Slit3 deletion in osteoblasts prevented PTH-reduction of endplate porosity and improvement in behavior tests, whereas PPR deletion in chondrocytes continued to respond to PTH. Altogether, PTH stimulates Slit3 to repel sensory nerve innervation and provides symptomatic relief of LBP associated with spinal degeneration.

Can a Novel Light Weight Minimal Support Lifting Exoskeleton Modify Lifting Movement in People without Low Back Pain?

Low back pain (LBP) is a major contributor to lifting-related disabilities. To minimize the risk of back pain, emerging technologies known as lifting exoskeletons were designed to optimize lifting movements. However, it is currently unknown whether a minimally supportive exoskeleton can alter the lifting movement in people without LBP. This study aims to investigate if wearing a novel lightweight exoskeleton that minimally supports the back, hip, and knee can alter the lifting range of motion and movement variations in people without LBP. This study also aims to investigate if wearing this novel exoskeleton can result in a reliable between-day lifting movement. In two separate sessions (each one week apart), fourteen participants lifted a box (that weighed 10% of their body weight) ten times, once while wearing an exoskeleton and once while not wearing an exoskeleton. Wearing the novel exoskeleton during lifting produced moderate-high, test-retest reliability (Trunk: ICC3,1 = 0.89, 95% CI [0.67, 0.96], SEM = 9.34°; Hip: ICC3,1 = 0.63, 95% CI [0.22, 0.88], SEM = 2.57°; Knee: ICC3,1 = 0.61, 95% CI [0.23, 0.87], SEM = 2.50°). Wearing an exoskeleton significantly decreased the range of motion of the knee (F1,4 = 4.83, p = 0.031, ηp2 = 0.06). Additionally, wearing an exoskeleton significantly decreased hip (diff = 8.38, p = 0.045) and knee (diff = -8.57, p = 0.038) movement variability; however, wearing an exoskeleton did not decrease the movement variability of the body's trunk (diff = 0.60, p = 1.00). Therefore, minimally supported lifting through the use of exoskeletons can modify movement in people without LBP and produce reliable lifting movements. Wearing the novel exoskeleton is also desirable for monitoring lifting movements. Future studies should investigate the use of sensors and IMU to monitor lifting movement at work with the least amount of intrusion on an individual's movement.

Beliefs and practice patterns of spinal thrust manipulation for mechanical low back pain of physical therapists in the state of Minnesota

INTRODUCTION

The primary purpose of this study was to examine the perceptions and utilization of spinal thrust manipulation (STM) techniques of physical therapists who treat patients with low back pain (LBP) in the State of Minnesota. A secondary purpose was to investigate differences between physical therapists who perform STM and those who do not.

METHODS

A cross-sectional design was utilized through the completion of an electronic survey. 74 respondents completed the survey. Descriptive measures were recorded as frequencies for categorical data or mean ± standard deviation for continuous data. For between-group comparisons, chi-square analyses were used for categorical items of nominal or ordinal data and t-tests were utilized for continuous data. The alpha level was set at p < 0.05.

RESULT

60.2% of respondents reported using STM when treating patients with LBP. 69.9% of respondents utilize a classification system. 76.7% of individuals answered correctly regarding the Minnesota State practice act. Of those who use STM, 81.8% utilize a Clinical Prediction Rule. Respondents who use STM were more likely to have a specialist certification (chi-square = 6.471, p = 0.011) and to have completed continuing education courses on manual therapy (chi-square = 4.736, p = 0.030).

DISCUSSION/CONCLUSIONS

Physical therapists who perform STM are more likely to have a better understanding of their state practice act, be board certified, and have completed continuing education in manual therapy.

Effects of yoga and add on Ayurvedic Kati Basti therapy for patients with chronic low back pain: A randomized controlled trial

BACKGROUND

Chronic low back pain (CLBP) signficantly affects quality of life and productivity, leading to limitations in mobility, activity, and potential work absenteesim. Yoga and Ayurveda have shown promising evidence in reducing pain, improve function, and enhancing well-being for individuals with CLBP, as demonstrated by numerous studies.

OBJECTIVES

The aim of this study is to assess the effect of a 1-week residential integrative approach to yoga therapy. (IAYT) alone versus when combined with Ayurveda therapy (Kati Basti) in patients with CLBP.

METHODS

Forty patients were recruited from E-section of a holistic health center in South India for randomization and split into a Yoga and Ayurveda (n=20) and a Yoga-only (n=20) group. Yoga and Ayurveda group received a 1-week residential program combining Yoga and Ayurveda (therapy including Kati Basti with Ksheerbala Taila), while the Yoga-only group received only yoga therapy. Assessments at baseline, 1-week, and three months were measure pain intensity, disability, and depression.

RESULTS

Both Yoga and Ayurveda group, and Yoga-only group showed significant reductions in pain and improvements in disability and depression at 1-week and three months. Quality of life also improved, specifically in physical, social, environmental, and psychological health. No significant differences were found between the groups in terms of pain, disability, and depression.

CONCLUSION

Both interventions demonstrated comparable results in pain reduction and disability improvement, as well as alleviating depression symptoms. Only Yoga and Ayurveda group exhibited improvement in physical health. Further research should explore long-term effects and compare different yoga interventions.

Efficacy of head postural correction program on craniovertebral angle, scapular position, and dominant hand grip strength in forward head posture subjects: A randomized controlled trial

OBJECTIVE

Forward head posture (FHP) is a common postural disorder that alters shoulder function. This study examined the efficacy of a corrective program involving postural correction exercises (PCEs), scapular stabilization exercises (SSEs), and kinesiotaping (KT) on improving craniovertebral angle (CVA), scapular position, and dominant hand grip strength (HGS) in individuals with FHP.

METHODS

Sixty subjects (8 males and 52 females, 18-40 years old) were randomly allocated into four equal groups: Group A: received PCEs only, Group B: received PCEs and SSEs, Group C: received PCEs and KT, Group D: received PCEs, SSEs and KT. All subjects received treatment for 4 weeks (4 times/week) and postural advice. Outcome measures included cranio-vertebral angle (CVA), scapular position using Lateral Scapular Slide Test and dominant HGS using a CAMRY dynamometer that were assessed at baseline and 4 weeks post intervention.

RESULTS

Comparing all groups post training revealed that there were statistically significant increases (p < 0.05) in all measured variables (CVA, scapular position and dominant HGS) in favor of group (D).

CONCLUSION

Combination of PCEs, SSEs and KT interventions has achieved the best gains in terms of CVA, dominant HGS and regaining optimal scapular position in FHP subjects.

Consensus methods in patellofemoral pain: how rigorous are they? A scoping review

OBJECTIVE

Clinicians treating patients with patellofemoral pain (PFP) rely on consensus statements to make the best practice recommendations in the absence of definitive evidence on how to manage PFP. However, the methods used to generate and assess agreement for these recommendations have not been examined. Our objective was to map the methods used to generate consensus-based recommendations for PFP and apply four novel questions to assess the rigour of consensus development.

DESIGN

Scoping review.

DATA SOURCES

We searched Medline, SPORTDiscus, CINAHL and Embase from inception to May 2022 to identify consensus-derived statements or practice guidelines on PFP. The Joanna Briggs Institute Manual for Evidence Synthesis was followed to map the existing evidence. We measured the consensus methods based on four sets of questions addressing the panel composition, application of the consensus method chosen, agreement process and the use of evidence mapping.

ELIGIBILITY CRITERIA

All consensus statements or clinical guidelines on PFP were considered.

RESULTS

Twenty-two PFP consensus statements were identified. Panel composition: 3 of the 22 (14%) consensus groups reported the panellists' experience, 2 (9%) defined a desired level of expertise, 10 (45%) reported panellist sex and only 2 (9%) included a patient. Consensus method: 7 of 22 (32%) reported using an established method of consensus measurement/development. Agreement process: 10 of 22 (45%) reported their consensus threshold and 2 (9%) acknowledged dissenting opinions among the panel. Evidence mapping: 6 of 22 (27%) reported using systematic methods to identify relevant evidence gaps.

CONCLUSIONS

PFP consensus panels have lacked diversity and excluded key partners including patients. Consensus statements on PFP frequently fail to use recognised consensus methods, rarely describe how 'agreement' was defined or measured and often neglect to use systematic methods to identify evidence gaps.

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists

INTRODUCTION

An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

METHOD

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

RESULTS

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined.

CONCLUSION

Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus

OBJECTIVE

To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions.

DATA SOURCES

A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years.

REVIEW METHODS

Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts.

RESULTS

Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain.

CONCLUSIONS

The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5-10 years.

The relationship between trust and outcomes during physical therapy care for chronic low back pain

INTRODUCTION

Enhancing the therapeutic alliance has been associated with improved outcomes for patients with chronic low back pain (CLBP). Qualitatively trust has been described to be part of the therapeutic alliance, but it has not been measured quantitatively within the physical therapy literature.

OBJECTIVE

Examine the relationship between trust and outcomes during physical therapy for CLBP.

METHODS

Observational study of patients with CLBP being seen for physical therapy were assessed through self-report measures. The Primary Care Assessment Survey (PCAS) trust measurement scale was completed by patients at initial, post-initial, and discharge visit. These measurements were compared for correlations with patient reported outcome measures for pain and function recorded at initial visit and discharge.

RESULTS

A convenience sample of 29 patients (49.3 ± 15 years old) with CLBP were measured. The PCAS showed correlations for changes in trust throughout treatment for improvements in pain and discharge pain rating. Average discharge pain rating correlated to changes in the PCAS (rs = -0.692, p < .001), with lower pain ratings relating to higher changes in trust over time. Average change in pain (rs = 0.745, p < .001) throughout treatment also correlated with higher changes in trust. Higher trust scores at discharge also correlated with improved Global Rating of Change and Oswestry Disability Index scores at discharge. The linear regression model showed adjusted R2 values for the trust scores and outcomes varied between 0.247 and 0.642.

CONCLUSION

Both increases in trust throughout the treatment and end trust scores during physical therapy were related to improved outcomes for patients with CLBP.