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Rodgers LJ, Bialosky JE, Minick SA, Coronado RA. An overview of systematic reviews examining the quantitative sensory testing-derived hypoalgesic effects of manual therapy for musculoskeletal pain. J Man Manip Ther 2024; 32:67-84. [PMID: 37908101 PMCID: PMC10795637 DOI: 10.1080/10669817.2023.2267954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/03/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Changes in quantitative sensory testing (QST) after manual therapy can provide insight into pain relief mechanisms. Prior systematic reviews have evaluated manual-therapy-induced QST change. This overview of systematic reviews aims to consolidate this body of literature and critically review evidence on the hypoalgesic effects of manual therapy in clinical populations. METHODS A comprehensive search was conducted on PubMed, CINAHL, PsycInfo, and Embase. Peer-reviewed systematic reviews with or without meta-analysis were eligible if the reviews examined the effect of manual therapy compared to non-manual therapy interventions on QST outcomes in clinical populations. Methodological quality was assessed with the AMSTAR 2 tool. Meta-analysis results and qualitative (non-meta-analysis) interpretations were summarized by type of manual therapy. Overlap of studies was examined with the corrected covered area (CCA) index. RESULTS Thirty systematic reviews, including 11 meta-analyses, met inclusion. There was a slight overlap in studies (CCA of 1.72% for all reviews and 1.69% for meta-analyses). Methodological quality was predominantly low to critically low. Eight (27%) reviews examined studies with a range of manual therapy types, 13 (43%) reviews focused on joint-biased manual therapy, 7 (23%) reviews focused on muscle-biased manual therapy, and 2 (7%) reviews focused on nerve-biased manual therapy. Twenty-nine (97%) reviews reported on pressure pain threshold (PPT). Meta-analytic results demonstrated conflicting evidence that manual therapy results in greater hypoalgesic effects compared to other interventions or controls. CONCLUSION Our overview of QST effects, which has relevance to mechanisms underlying hypoalgesia, shows conflicting evidence from mostly low to critically low systematic reviews.
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Affiliation(s)
- Logan J. Rodgers
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Joel E. Bialosky
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
- Brooks-UF-PHHP Research Collaboration, Gainesville, FL, USA
| | - Sophie A. Minick
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rogelio A. Coronado
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Avila L, da Silva MD, Neves ML, Abreu AR, Fiuza CR, Fukusawa L, de Sá Ferreira A, Meziat-Filho N. Effectiveness of Cognitive Functional Therapy Versus Core Exercises and Manual Therapy in Patients With Chronic Low Back Pain After Spinal Surgery: Randomized Controlled Trial. Phys Ther 2024; 104:pzad105. [PMID: 37548608 DOI: 10.1093/ptj/pzad105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 03/28/2023] [Accepted: 06/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Our aim was to investigate whether cognitive functional therapy (CFT) was more effective than core exercises and manual therapy (CORE-MT) in improving pain and function for patients with chronic low back pain after spinal surgery. METHODS This study was a randomized controlled superiority trial in a university hospital and a private physical therapist clinic in Santa Catarina, Brazil. Eighty participants who were 18 to 75 years old and had chronic low back pain after spinal surgery received 4 to 12 treatment sessions of CFT or CORE-MT once per week for a maximum period of 12 weeks. Primary outcomes were pain intensity (numeric pain rating scale, scored from 0 to 10) and function (Patient-Specific Functional Scale, scored from 0 to 10) after intervention. RESULTS We obtained primary outcome data for 75 participants (93.7%). CFT was more effective, with a large effect size, than CORE-MT in reducing pain intensity (mean difference [MD] = 2.42; 95% CI = 1.69-3.14; effect size [d] = 0.85) and improving function (MD = -2.47; 95% CI = -3.08 to -1.87; effect size = 0.95) after intervention (mean = 10.4 weeks [standard deviation = 2.17] after the beginning of treatment). The differences were maintained at 22 weeks for pain intensity (MD = 1.64; 95% CI = 0.98-2.3; effect size = 0.68) and function (MD = -2.01; 95% CI = -2.6 to -1.41; effect size = 0.81). CONCLUSION CFT was more effective than CORE-MT, with large effect sizes, and may be an option for patients with chronic low back pain after spinal surgery. IMPACT CFT reduces pain and improves function, with large effect sizes, compared with CORE-MT. The difference between CFT and CORE-MT was sustained at the midterm follow-up. Treatment with CFT may be an option for patients with chronic low back pain after spinal surgery.
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Affiliation(s)
- Leonardo Avila
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Morgana Duarte da Silva
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Marcos Lisboa Neves
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Andre Rogerio Abreu
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Cibelle Ramos Fiuza
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
- Multicenter Postgraduate Program in Physiological Sciences, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Leandro Fukusawa
- Masters and Doctoral Programs in Medical Sciences, Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Arthur de Sá Ferreira
- Postgraduate Program in Rehabilitation Sciences, Centro Universitário Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
| | - Ney Meziat-Filho
- Postgraduate Program in Rehabilitation Sciences, Centro Universitário Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
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Koppenaal T, van Dongen JM, Kloek CJ, Arensman RM, Veenhof C, Pisters MF, Ostelo RW. Effectiveness and Cost-Effectiveness of a Stratified Blended Physiotherapy Intervention Compared With Face-to-Face Physiotherapy in Patients With Nonspecific Low Back Pain: Cluster Randomized Controlled Trial. J Med Internet Res 2023; 25:e43034. [PMID: 37999947 PMCID: PMC10709796 DOI: 10.2196/43034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/06/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Nonspecific low back pain (LBP) is a leading contributor to disability worldwide, and its socioeconomic burden is substantial. Self-management support is an important recommendation in clinical guidelines for the physiotherapy treatment of patients with LBP and may support cost-effective management. However, providing adequate individually tailored self-management support is difficult. The integration of web-based applications into face-to-face care (ie, blended care) seems promising to optimize tailored treatment and enhance patients' self-management and, consequently, may reduce LBP-related costs. OBJECTIVE We aimed to evaluate the long-term effectiveness and cost-effectiveness of stratified blended physiotherapy (e-Exercise LBP) compared with face-to-face physiotherapy in patients with nonspecific LBP. METHODS An economic evaluation was conducted alongside a prospective, multicenter, cluster randomized controlled trial in primary care physiotherapy. Patients with nonspecific LBP were treated with either stratified blended physiotherapy (e-Exercise LBP) (n=104) or face-to-face physiotherapy (n=104). The content of both interventions was based on the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients' risk of developing persistent LBP using the STarT Back Screening Tool. The primary clinical outcome was physical functioning (Oswestry Disability Index version 2.1a). For the economic evaluation, quality-adjusted life years (QALYs; EQ-5D-5L) and physical functioning were the primary outcomes. Secondary clinical outcomes included fear avoidance beliefs and self-reported adherence. Costs were measured from societal and health care perspectives using self-report questionnaires. Effectiveness was estimated using linear mixed models. Seemingly unrelated regression analyses were conducted to estimate total cost and effect differences for the economic evaluation. RESULTS Neither clinically relevant nor statistically substantial differences were found between stratified blended physiotherapy and face-to-face physiotherapy regarding physical functioning (mean difference [MD] -1.1, 95% CI -3.9 to 1.7) and QALYs (MD 0.026, 95% CI -0.020 to 0.072) over 12 months. Regarding the secondary outcomes, fear avoidance beliefs showed a statistically significant improvement in favor of stratified blended physiotherapy (MD -4.3, 95% CI -7.3 to -1.3). Societal and health care costs were higher for stratified blended physiotherapy than for face-to-face physiotherapy, but the differences were not statistically significant (societal: €972 [US $1027], 95% CI -€1090 to €3264 [US -$1151 to $3448]; health care: €73 [US $77], 95% CI -€59 to €225 [US -$62 to $238]). Among the disaggregated cost categories, only unpaid productivity costs were significantly higher for stratified blended physiotherapy. From both perspectives, a considerable amount of money must be paid per additional QALY or 1-point improvement in physical functioning to reach a relatively low to moderate probability (ie, 0.23-0.81) of stratified blended physiotherapy being cost-effective compared with face-to-face physiotherapy. CONCLUSIONS The stratified blended physiotherapy intervention e-Exercise LBP is neither more effective for improving physical functioning nor more cost-effective from societal or health care perspectives compared with face-to-face physiotherapy for patients with nonspecific LBP. TRIAL REGISTRATION ISRCTN 94074203; https://www.isrctn.com/ISRCTN94074203. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s12891-020-3174-z.
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Affiliation(s)
- Tjarco Koppenaal
- Research Group Empowering Healthy Behaviour, Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Public Health research institute, Amsterdam, Netherlands
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences research institute Amsterdam, Amsterdam, Netherlands
| | - Corelien Jj Kloek
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
- Research Group Innovation of Human Movement Care, Research Center Healthy and Sustainable Living, HU University of Applied Sciences, Utrecht, Netherlands
| | - Remco M Arensman
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Cindy Veenhof
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
- Research Group Innovation of Human Movement Care, Research Center Healthy and Sustainable Living, HU University of Applied Sciences, Utrecht, Netherlands
| | - Martijn F Pisters
- Research Group Empowering Healthy Behaviour, Department of Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
- Physical Therapy Research, Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Raymond Wjg Ostelo
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences research institute Amsterdam, Amsterdam, Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location Vrije Universiteit, Amsterdam, Netherlands
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Wilson AT, Riley JL, Bishop MD, Beneciuk JM, Cruz-Almeida Y, Markut K, Redd C, LeBlond N, Pham PH, Shirey D, Bialosky JE. Pain phenotyping and investigation of outcomes in physical therapy: An exploratory study in patients with low back pain. PLoS One 2023; 18:e0281517. [PMID: 36787322 PMCID: PMC9928110 DOI: 10.1371/journal.pone.0281517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023] Open
Abstract
Phenotypes have been proposed as a method of characterizing subgroups based on biopsychosocial factors to identify responders to analgesic treatments. This study aimed to, first, confirm phenotypes in patients with low back pain receiving physical therapy based on an a priori set of factors used to derive subgroups in other pain populations. Second, an exploratory analysis examined if phenotypes differentiated pain and disability outcomes at four weeks of physical therapy. Fifty-five participants completed psychological questionnaires and pressure pain threshold (PPT). Somatization, anxiety, and depression domains of the Symptom-Checklist-90-Revised, and PPT, were entered into a hierarchical agglomerative cluster analysis with Ward's method to identify phenotypes. Repeated measures ANOVAs assessed pain ratings and disability by phenotype at four weeks. Three clusters emerged: 1) high emotional distress and pain sensitivity (n = 10), 2) low emotional distress (n = 34), 3) low pain sensitivity (n = 11). As an exploratory study, clusters did not differentiate pain ratings or disability after four weeks of physical therapy (p's>0.05). However, trends were observed as magnitude of change for pain varied by phenotype. This supports the characterization of homogenous subgroups based on a protocol conducted in the clinical setting with varying effect sizes noted by phenotype for short-term changes in pain. As an exploratory study, future studies should aim to repeat this trial in a larger sample of patients.
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Affiliation(s)
- Abigail T. Wilson
- School of Kinesiology and Rehabilitation Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, United States of America
- * E-mail:
| | - Joseph L. Riley
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, United States of America
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Mark D. Bishop
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
| | - Jason M. Beneciuk
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - Yenisel Cruz-Almeida
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, United States of America
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Keri Markut
- University of Florida Health Rehab Center-Orthopedic and Sports Medicine Institute, Gainesville, Florida, United States of America
| | - Charlotte Redd
- University of Florida Health Rehab Center-Orthopedic and Sports Medicine Institute, Gainesville, Florida, United States of America
| | - Nicholas LeBlond
- Duke University Health System Durham, North Carolina, United States of America
| | - Patrick H. Pham
- Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - David Shirey
- Brooks Rehabilitation, Jacksonville, Florida, United States of America
| | - Joel E. Bialosky
- University of Florida Department of Physical Therapy, Gainesville, Florida, United States of America
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida, United States of America
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Hall K, Grinstead A, Lewis JS, Mercer C, Moore A, Ridehalgh C. Rotator cuff related shoulder pain. Describing home exercise adherence and the use of behavior change interventions to promote home exercise adherence: a systematic review of randomized controlled trials. PHYSICAL THERAPY REVIEWS 2021. [DOI: 10.1080/10833196.2021.1935106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kevin Hall
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Anthony Grinstead
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Jeremy S. Lewis
- School of Health and Social Work, University of Hertfordshire, Hertfordshire, United Kingdom
- Therapy Department, Central London Community Healthcare National Health Service Trust, London, United Kingdom
- Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar
| | - Chris Mercer
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Ann Moore
- School of Health Sciences, University of Brighton, Eastbourne, East Sussex, United Kingdom
| | - Colette Ridehalgh
- School of Health Sciences, University of Brighton, Eastbourne, United Kingdom
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Peek AL, Leaver AM, Foster S, Oeltzschner G, Puts NA, Galloway G, Sterling M, Ng K, Refshauge K, Aguila MER, Rebbeck T. Increased GABA+ in People With Migraine, Headache, and Pain Conditions- A Potential Marker of Pain. THE JOURNAL OF PAIN 2021; 22:1631-1645. [PMID: 34182103 DOI: 10.1016/j.jpain.2021.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/25/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Abstract
Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstrate modest results. A greater understanding of underlying pain mechanisms may better inform treatments and improve outcomes. Increased GABA+ has been identified in recent studies of migraine, however, it is unclear if this is present in other headache, and pain conditions. We primarily investigated GABA+ levels in the posterior cingulate gyrus (PCG) of people with migraine, whiplash-headache and low back pain compared to age- and sex-matched controls, GABA+ levels in the anterior cingulate cortex (ACC) and thalamus formed secondary aims. Using a cross-sectional design, we studied people with migraine, whiplash-headache or low back pain (n = 56) and compared them with a pool of age- and sex-matched controls (n = 22). We used spectral-edited magnetic resonance spectroscopy at 3T (MEGA-PRESS) to determine levels of GABA+ in the PCG, ACC and thalamus. PCG GABA+ levels were significantly higher in people with migraine and low back pain compared with controls (eg, migraine 4.89 IU ± 0.62 vs controls 4.62 IU ± 0.38; P = .02). Higher GABA+ levels in the PCG were not unique to migraine and could reflect a mechanism of chronic pain in general. A better understanding of pain at a neurochemical level informs the development of treatments that target aberrant brain neurochemistry to improve patient outcomes. PERSPECTIVE: This study provides insights into the underlying mechanisms of chronic pain. Higher levels of GABA+ in the PCG may reflect an underlying mechanism of chronic headache and pain conditions. This knowledge may help improve patient outcomes through developing treatments that specifically address this aberrant brain neurochemistry.
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Affiliation(s)
- Aimie L Peek
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Queensland, Australia.
| | - Andrew M Leaver
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sheryl Foster
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Radiology, Westmead Hospital, New South Wales, Australia
| | - Georg Oeltzschner
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland
| | - Nicolaas A Puts
- Department of Forensic and Neurodevelopmental Sciences, Sackler Institute for Translational Neurodevelopment, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK; MRC Centre for Neurodevelopmental Disorders, King's College London, UK
| | - Graham Galloway
- The University of Queensland, Brisbane, Queensland, Australia; Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Michele Sterling
- NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Queensland, Australia; RECOVER Injury Research Centre, Herston, Queensland, Australia
| | - Karl Ng
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Neurology, Royal North Shore Hospital, New South Wales, Australia
| | - Kathryn Refshauge
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Trudy Rebbeck
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Queensland, Australia
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Idowu OA, Adeniyi AF, Edo A, Fasanmade A. Graded activity with and without daily-monitored-walking in patients with type 2 diabetes with low back pain: secondary analysis of a randomized-clinical trial. Arch Physiother 2021; 11:10. [PMID: 33853682 PMCID: PMC8048054 DOI: 10.1186/s40945-021-00104-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 03/04/2021] [Indexed: 12/19/2022] Open
Abstract
Background Graded activity is gradually emerging as a preferred choice in improving psychosocial outcomes including pain self-efficacy, fear-avoidance beliefs, and back-pain beliefs in the general population with low back pain (LBP). Such evidence is, however, lacking among patients with concomitant LBP and type-2 diabetes mellitus (T2DM). This secondary analysis of a randomized control trial aimed to compare the efficacy between graded activity augmented with additional daily-monitored-walking and graded activity alone on disability, pain self-efficacy (PSE), fear-avoidance beliefs (FAB), back-pain beliefs (BPB) and glycaemic control (HbA1c) in patients with concomitant LBP and T2DM. Methods Fifty-eight patients with concomitant LBP and T2DM were randomised into two groups, graded activity with daily-monitored-walking group (GAMWG = 29) or (graded activity group (GAG = 29) in this 12-week single-blind trial. Both groups received graded activity (home/work-place visits, back school and sub-maximal exercises) while the GAMWG received additional daily-monitored-walking. Disability and selected psychosocial outcomes were assessed at weeks 0, 4, 8 and 12 using Roland-Morris disability, fear-avoidance behaviour, pain self-efficacy and back belief questionnaires. Glycaemic control was assessed at weeks 0 and 12 using a point-of-care system (In2it, Biorad Latvia). Data were analysed using mean, median, Friedman’s ANOVA, Mann-Whitney test and t-tests. Results Participants’ mean age was 48.3 ± 9.4 years (95%CI: 45.6, 50.9) while 35.3% were males. The GAMWG participants (n = 25) had better outcomes (P < 0.05) than GAG participants (n = 26) on PSE (1.0, 3.0; r = − 0.1) and FAB (0.01, − 2.0; r = − 0.1) at week 4, LBP-related disability (0.01, − 2.0; r = − 0.2) at week 8 and glycaemic control at week 12 (− 0.59 ± 0.51%,-0.46 ± 0.22%). No other between-group comparisons were statistically significant. Conclusion Graded activity with daily-monitored-walking provided earlier improvements on disability, pain self-efficacy, fear-avoidance beliefs, and glycaemic control, but not back pain beliefs, in patients with concomitant LBP and T2DM. Trial registration PACTR201702001728564; 26 July, 2016 (retrospectively registered).
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Affiliation(s)
- Opeyemi Ayodiipo Idowu
- Department of Physiotherapy, College of Medical Sciences, School of Basic Medical Sciences, University of Benin, Benin City, Nigeria.
| | - Ade Fatai Adeniyi
- Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Andrew Edo
- Deparment of Medicine, University of Benin, Benin City, Nigeria
| | - Adesoji Fasanmade
- Department of Physiology, College of Medicine, University of Ibadan, Ibadan, Nigeria
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8
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Sanchis-Sánchez E, Lluch-Girbés E, Guillart-Castells P, Georgieva S, García-Molina P, Blasco JM. Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis. Braz J Phys Ther 2020; 25:117-134. [PMID: 32773288 DOI: 10.1016/j.bjpt.2020.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/06/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To determine the effectiveness of mechanical diagnosis and therapy (MDT) in patients with chronic low back pain (CLBP) compared to other traditional physical therapy interventions. METHODS Randomized controlled trials investigating the effect of MDT compared to other traditional physical therapy interventions in individuals with CLBP were considered eligible. For the purpose of this review, MDT was compared to active and passive physical therapy interventions. Independent reviewers assessed the eligibility of studies, extracted data, and assessed the risk of bias. The primary outcomes investigated were pain and disability. RESULTS Fourteen studies were included in the review. Of these, 11 provided data to be included in the meta-analyses. Our findings showed that MDT was no more effective in decreasing pain (standardized mean difference [SMD]=0.01, 95% confidence interval [CI]: -0.44, 0.46) and disability (SMD=0.08, 95% CI: -0.53, 0.68) than other active treatments. Similar results were found when comparing MDT to other passive treatments for pain (SMD=-0.39, 95% CI: -0.90, 0.11) and disability (SMD=-0.13, 95% CI: -0.29, 0.03). CONCLUSION There is low to moderate quality evidence that MDT is not superior than other traditional physical therapy interventions in improving pain and disability in people with CLBP.
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Affiliation(s)
- Enrique Sanchis-Sánchez
- Department of Physical Therapy, University of Valencia, Valencia, Spain; IRIMED Joint Research Unit (La Fe - UV), Valencia, Spain
| | - Enrique Lluch-Girbés
- Department of Physical Therapy, University of Valencia, Valencia, Spain; Pain in Motion Research Group, Department of Human Physiology (Chropiver), Vrije Universiteit, Brussels, Belgium.
| | | | - Sylvia Georgieva
- Department of Methodology and Behavioral Sciences, University of Valencia, Valencia, Spain
| | | | - Jose-María Blasco
- Department of Physical Therapy, University of Valencia, Valencia, Spain; Group of Physiotherapy in the Ageing Processes: Socio-sanitary and Healthcare Strategies, Valencia, Spain; IRIMED Joint Research Unit (La Fe - UV), Valencia, Spain
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9
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Comparison of Hip and Lumbopelvic Performance Between Chronic Low Back Pain Patients Suited for the Functional Optimization Approach and Healthy Controls. Spine (Phila Pa 1976) 2020; 45:E37-E44. [PMID: 31415454 DOI: 10.1097/brs.0000000000003198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE We explored the differences between chronic low back pain (CLBP) patients suited for the functional optimization approach and healthy controls in isometric hip-strength and lumbar-endurance tests and determined classificatory cutoff values for strength and endurance tests and ratios. SUMMARY OF BACKGROUND DATA To optimize the treatment effect for CLBP, some approaches have classified patients into homogeneous subgroups matched to specific treatments. We evaluated CLBP patients suited for the functional optimization approach, who seek care because they experience symptoms during activities with high physical demands, although they are relatively asymptomatic. METHODS Three hundred fifty subjects (healthy controls, 170; CLBP patients, 180) were stratified by age (18-40 and 41-65 yrs), sex, and physical activity level. The CLBP patients had an Oswestry Disability Index score < 20% and a Numeric Pain Rating Scale score < 3. The subjects underwent hip abductor, extensor, and flexor isometric strength tests; a deep abdominal function test; and lateral/frontal bridge and lumbar flexor/extensor endurance tests. RESULTS Relative to the healthy controls, the CLBP patients showed significantly (P > 0.05) higher strength scores in the hip flexor and deep abdominal function tests but lower endurance in the lateral and frontal bridge and lumbar flexor and extensor tests. The cutoff values of the lumbar flexor test and the lumbar flexor/extensor, lateral bridge/lumbar flexor, frontal bridge/lumbar flexor, and hip extensor/flexor test ratios showed acceptable accuracy (AUC = 0.84, 0.82, 0.79, 0.75, and 0.73, respectively). CONCLUSION In lumbopelvic and hip-performance tests, CLBP patients suited for the functional optimization approach showed differences from healthy controls. These patients could be discriminated from healthy controls on the basis of accurate cutoff values for strength and endurance tests and ratios, which should be considered in treatment decision-making when patients need to return to activities with higher physical demands. LEVEL OF EVIDENCE 2.
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Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare. Musculoskelet Sci Pract 2019; 41:6-14. [PMID: 30818071 DOI: 10.1016/j.msksp.2019.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed. OBJECTIVE The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare. DESIGN This was an explorative study using qualitative content analysis. METHOD Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities). CONCLUSION This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.
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Tackling low back pain in Brazil: a wake-up call. Braz J Phys Ther 2018; 23:189-195. [PMID: 30337255 DOI: 10.1016/j.bjpt.2018.10.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/28/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society. OBJECTIVE This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.
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Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through stratified care (STarT Back). Braz J Phys Ther 2018; 22:255-264. [PMID: 29970301 PMCID: PMC6095099 DOI: 10.1016/j.bjpt.2018.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/07/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care. RESULTS The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care. CONCLUSIONS The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.
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Affiliation(s)
- Gail Sowden
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK; Interdisciplinary Musculoskeletal Pain Assessment and Community Treatment Service, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent ST6 7AG, UK.
| | - Jonathan Charles Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Lars Morso
- Centre for Quality, Department of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 3 Odense C DK 5000, Denmark
| | - Quninette Louw
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nadine Elizabeth Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
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Chiarotto A, Boers M, Deyo RA, Buchbinder R, Corbin TP, Costa LO, Foster NE, Grotle M, Koes BW, Kovacs FM, Lin CWC, Maher CG, Pearson AM, Peul WC, Schoene ML, Turk DC, van Tulder MW, Terwee CB, Ostelo RW. Core outcome measurement instruments for clinical trials in nonspecific low back pain. Pain 2018; 159:481-495. [PMID: 29194127 PMCID: PMC5828378 DOI: 10.1097/j.pain.0000000000001117] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/09/2017] [Accepted: 11/15/2017] [Indexed: 01/09/2023]
Abstract
To standardize outcome reporting in clinical trials of patients with nonspecific low back pain, an international multidisciplinary panel recommended physical functioning, pain intensity, and health-related quality of life (HRQoL) as core outcome domains. Given the lack of a consensus on measurement instruments for these 3 domains in patients with low back pain, this study aimed to generate such consensus. The measurement properties of 17 patient-reported outcome measures for physical functioning, 3 for pain intensity, and 5 for HRQoL were appraised in 3 systematic reviews following the COSMIN methodology. Researchers, clinicians, and patients (n = 207) were invited in a 2-round Delphi survey to generate consensus (≥67% agreement among participants) on which instruments to endorse. Response rates were 44% and 41%, respectively. In round 1, consensus was achieved on the Oswestry Disability Index version 2.1a for physical functioning (78% agreement) and the Numeric Rating Scale (NRS) for pain intensity (75% agreement). No consensus was achieved on any HRQoL instrument, although the Short Form 12 (SF12) approached the consensus threshold (64% agreement). In round 2, a consensus was reached on an NRS version with a 1-week recall period (96% agreement). Various participants requested 1 free-to-use instrument per domain. Considering all issues together, recommendations on core instruments were formulated: Oswestry Disability Index version 2.1a or 24-item Roland-Morris Disability Questionnaire for physical functioning, NRS for pain intensity, and SF12 or 10-item PROMIS Global Health form for HRQoL. Further studies need to fill the evidence gaps on the measurement properties of these and other instruments.
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Affiliation(s)
- Alessandro Chiarotto
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Richard A. Deyo
- Department of Family Medicine, Department of Internal Medicine, and Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
| | - Terry P. Corbin
- Cochrane Collaboration, Back and Neck Review Group, Maple Grove, MN, USA
| | - Leonardo O.P. Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Margreth Grotle
- Oslo and Akershus University College, Faculty of Health Science, Oslo, Norway
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital & University of Oslo, Oslo, Norway
| | - Bart W. Koes
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francisco M. Kovacs
- Spanish Back Pain Research Network, Hospital Universitario HLA-Moncloa, Madrid, Spain
| | - C.-W. Christine Lin
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chris G. Maher
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Adam M. Pearson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, PA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark L. Schoene
- Cochrane Collaboration, Back and Neck Review Group, Newbury, MA, USA
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Maurits W. van Tulder
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Caroline B. Terwee
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Raymond W. Ostelo
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
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Abstract
The burden that low back pain (LBP) presents to sufferers and society is well established. This ubiquitous condition is served by a complex global clinical marketplace offering a wide range of assessment alternatives and accompanying interventions. Yet, while the costs of care are rising, the global burden does not appear to be diminishing. Considerable effort internationally has gone into developing CPGs for LBP. The authors highlight the similarities and differences between existing CPGs for LBP, as well as strengths, weaknesses, and opportunities for improvement in the implementation of guidelines generally. J Orthop Sports Phys Ther 2018;48(2):54-57. doi:10.2519/jospt.2018.0602.
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Nicholl BI, Sandal LF, Stochkendahl MJ, McCallum M, Suresh N, Vasseljen O, Hartvigsen J, Mork PJ, Kjaer P, Søgaard K, Mair FS. Digital Support Interventions for the Self-Management of Low Back Pain: A Systematic Review. J Med Internet Res 2017; 19:e179. [PMID: 28550009 PMCID: PMC5466697 DOI: 10.2196/jmir.7290] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/13/2017] [Accepted: 03/18/2017] [Indexed: 01/07/2023] Open
Abstract
Background Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health. Objective The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes? Methods Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively. Results Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm. Conclusions The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak.
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Affiliation(s)
- Barbara I Nicholl
- General Practice & Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Louise F Sandal
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Mette J Stochkendahl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Marianne McCallum
- General Practice & Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Nithya Suresh
- General Practice & Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ottar Vasseljen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Paul J Mork
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Per Kjaer
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Karen Søgaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Frances S Mair
- General Practice & Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
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