Unraveling the Complexity of Low Back Pain

Assessing the performance of AI chatbots in answering patients' common questions about low back pain

OBJECTIVES

The aim of this study was to assess the accuracy and readability of the answers generated by large language model (LLM)-chatbots to common patient questions about low back pain (LBP).

METHODS

This cross-sectional study analysed responses to 30 LBP-related questions, covering self-management, risk factors and treatment. The questions were developed by experienced clinicians and researchers and were piloted with a group of consumer representatives with lived experience of LBP. The inquiries were inputted in prompt form into ChatGPT 3.5, Bing, Bard (Gemini) and ChatGPT 4.0. Responses were evaluated in relation to their accuracy, readability and presence of disclaimers about health advice. The accuracy was assessed by comparing the recommendations generated with the main guidelines for LBP. The responses were analysed by two independent reviewers and classified as accurate, inaccurate or unclear. Readability was measured with the Flesch Reading Ease Score (FRES).

RESULTS

Out of 120 responses yielding 1069 recommendations, 55.8% were accurate, 42.1% inaccurate and 1.9% unclear. Treatment and self-management domains showed the highest accuracy while risk factors had the most inaccuracies. Overall, LLM-chatbots provided answers that were 'reasonably difficult' to read, with a mean (SD) FRES score of 50.94 (3.06). Disclaimer about health advice was present around 70%-100% of the responses produced.

CONCLUSIONS

The use of LLM-chatbots as tools for patient education and counselling in LBP shows promising but variable results. These chatbots generally provide moderately accurate recommendations. However, the accuracy may vary depending on the topic of each question. The reliability level of the answers was inadequate, potentially affecting the patient's ability to comprehend the information.

Pain neuroscience education is not superior to spinal physiology and ergonomics education within a short multidisciplinary rehabilitation program: A randomized controlled trial

INTRODUCTION

There is little evidence to suggest that one educational intervention is superior to another when associated with a rehabilitation program in the management of persistent low back pain. The objective of the present study was to compare pain neuroscience education with spine physiology and ergonomics education as part of a one-week multidisciplinary rehabilitation program.

METHOD

We conducted a randomized, controlled trial among patients having experienced persistent low back pain for at least 1 year. The patients participated in a one-week multidisciplinary rehabilitation program with an educational component. The members of the experimental and control groups received pain neuroscience education and spine physiology and ergonomics education, respectively. Outcomes were assessed before the program (day 0), immediately afterwards (day 5), and on day 90 after the start of the program. The primary outcome measure was functional disability on day 90.

RESULTS

A total of 88 patients were randomized. On day 90, a statistically significant mean [95% confidence interval] decrease in the level of disability was observed in the experimental (PNE) group (-3.4 [-5.0 to -1.8]). The mean [95%CI] difference versus the control group (-1.7 [-4.0 to 0.5]) was not statistically significant (p = 0.12). There were no statistically significant intergroup differences in the secondary outcome measures.

CONCLUSION

There appears to be no advantage in replacing a conventional, non-neuroscientific educational program (based on spinal physiology and ergonomics) with a pain neuroscience education program as part of a one-week multidisciplinary rehabilitation program. Further research is needed to identify patients who will respond better to a pain neuroscience education module as part of a personalized care program.

An Exploration of Low Back Beliefs of Male Pre-Professional and Professional Dancers

BACKGROUND

Globally, male dancers are affected by low back pain (LBP) up to 2.5 times more than female dancers. While female dancers' beliefs around LBP and dance-specific low back movements exist, no research has explored male dancers' beliefs. This study aimed to (1) examine the low back beliefs of Australian male professional and pre-professional dancers, and (2) determine if beliefs toward common low back movements and lifting differed when current LBP or history of disabling LBP (DLBP) were considered.

METHODS

40 male dancers (mean age [SD] 26.9 years [7.9]) from a range of dance backgrounds (all participating in ballet) were recruited to complete a cross-sectional survey comprising a beliefs questionnaire considering dance-specific movement and lifting tasks, the Back Pain Attitudes Questionnaire (Back-PAQ) and the Athletic Fear Avoidance Questionnaire (AFAQ). Primary analysis included initial descriptives, a repeated measures ANOVA for movement-specific beliefs and visual thematic analysis for written responses within the belief's questionnaire. Secondary subgroup analysis included independent T-tests for those with/without current LBP and those with/without a history of DLBP.

RESULTS

Fourteen dancers reported current LBP and 30 reported a history of DLBP. Dancers held generally negative beliefs toward the low back (Back-PAQ mean 123.1 ± 9.7) with neither subgroup demonstrating significant between-group difference (P < .05). Dance-specific flexion movements were seen as safer than extension movements (P < .05), and more extended-spine lifting was seen as safer than more flexed-spine lifting (P < .05). Dancers experiencing current LBP held less positive beliefs surrounding some dance-specific movements.

CONCLUSIONS

Dancers hold negative general beliefs toward the low back irrespective of current or historical DLBP, however their beliefs surrounding dance-specific movements were relatively positive. Dancers' beliefs surrounding some movements were affected by the presence of current LBP, in particular an arabesque and a fish dive.

The Association of Physiotherapy and Opioid Use With Duration of Compensated Time Loss for Workers With Low Back Pain

OBJECTIVE

To determine patterns of physiotherapy and opioid use among compensated workers with low back pain (LBP), factors associated with these, and their association with time loss.

METHODS

Accepted Victorian and South Australian workers' compensation claims, services, and medicines data for LBP claims lodged June 30, 2010-July 1, 2015. Descriptive statistics, multinomial logistic, and Cox regression were used to determine usage groups, their predictors, and effect of these on time loss.

RESULTS

Of 15,728 claims, 24.4% received no services, 3.6% received opioids only, 43.3% received physiotherapy only, and 28.8% received both opioids and physiotherapy. Sex, age, occupation, remoteness, jurisdiction, and socioeconomic status were significantly associated with usage groups. Using opioids and physiotherapy had the longest time loss.

CONCLUSIONS

Any services/medicine usage was associated with increased time loss and was longest for combined physiotherapy and opioids.

The Swedish version of the back pain attitudes questionnaire - Translation, cross-cultural adaptation and validation

BACKGROUND

Psychosocial factors influence low back pain (LBP) and guidelines recommend assessing unhelpful beliefs. The Back Pain Attitudes Questionnaire (Back-PAQ) is an instrument developed to assess LBP attitudes and beliefs. There is currently no Swedish translation of Back-PAQ.

OBJECTIVES

To translate and culturally adapt the Back-PAQ into Swedish (Back-PAQ-S) and to test its measurement properties.

DESIGN

Study of diagnostic accuracy/assessment scale.

METHODS

The cultural adaptation followed established guidelines and 120 individuals with and without nonspecific LBP (NSLBP) were recruited for the assessment of Back-PAQ-S's internal consistency, test-retest reliability, standard error of measurement (SEM) and smallest detectable change (SDC). Construct validity was assessed by testing hypotheses regarding Back-PAQ-S's relationship to the Back Beliefs Questionnaire (BBQ) and Tampa Scale of Kinesiophobia (TSK).

RESULTS

The Back-PAQ was translated and culturally adapted to Swedish. Expert panelists and informants thought items were relevant, comprehensive, and understandable. Back-PAQ-S of all lengths (34, 20 and 10-items) showed good internal consistency (Cronbach's α 0.95, 0.91 and 0.82) and excellent test-retest reliability (Intraclass correlation coefficient (ICC) 0.97, 0.96 and 0.95). The SEM was found to be 4.28, 3.13 and 1.66, and the SDC to be 11.85, 8.68 and 4.59 respectively. The Back-PAQ-S showed high positive correlations (Spearman's rho (rs) 0.78, 0.76 and 0.72) to the BBQ and moderate negative correlations (rs -0.67, -0.50 and -0.69) to the TSK.

CONCLUSION

The Back-PAQ-S has good validity and excellent reliability. It is viable for clinical and research use to assess LBP attitudes and beliefs in Swedish populations with and without NSLBP.

Measurement Properties of Two Questionnaires Assessing Fear-Avoidance in Patients With Chronic Low Back Pain

The Fear-Avoidance Components Scale (FACS) and the Fear of Daily Activities Questionnaire (FDAQ) assess fear-avoidance model components. However, the questionnaires are not available in Brazilian Portuguese. This study aimed to translate the original English FACS and FDAQ into Brazilian (Br) Portuguese and assess their measurement properties in patients with Chronic Low Back Pain (CLBP). One hundred thirty volunteers with CLBP participated in this study. Structural validity, internal consistency, test-retest reliability, and hypothesis testing for construct validity were analyzed. Results indicated a 2-factor solution for the FACS-Br, while the FDAQ-Br had a one-factor solution. Internal consistency showed acceptable Cronbach's alpha (alpha >.8). Suitable reliability was found for the FDAQ-Br (Intraclass Correlation Coefficient [ICC] = .98). For both FACS-Br factors, suitable reliability was found as well (ICC = .95 and .94). Hypothesis testing for construct validity confirmed more than 75% of the hypotheses proposed a priori for the FACS maladaptive pain/movement-related beliefs domain and the FDAQ-Br. In conclusion, the FACS-Br and FDAQ-Br demonstrated acceptable reliability, internal consistency, and structural validity measurement properties and their correlation (r < .50) suggests that the tools are not interchangeable measures.

Effectiveness of simultaneous bilateral visual diaphragm biofeedback under low back pain: influence of age and sex

Introduction: The aim of the present study was to determine the effectiveness of simultaneous bilateral visual diaphragm biofeedback (BFB) from ultrasonography in conjunction with inspiratory muscle training (IMT) on diaphragmatic thickness during normal breathing and respiratory and clinical outcomes in patients with non-specific low back pain (NSLBP) and determine the influence of age and sex. Methods: A single-blind randomized clinical trial was carried out (NCT04582812). A total sample of 96 patients with NSLBP was recruited and randomized by sex-based stratification into IMT (n = 48) and BFB + IMT (n = 48) interventions over 8 weeks. Bilateral diaphragmatic thickness at maximum inspiration (Tins) and expiration (Texp), respiratory pressures, lung function, pain intensity, bilateral pressure pain threshold (PPT), disability, and quality of life were measured at baseline and after 8 weeks. Results: The BFB + IMT group showed significant differences (p < 0.05) with increased left hemidiaphragm thickness at Tins and Tins-exp (d = 0.38-053), and right and left PPT (d = 0.71-0.74) versus the IMT group. The interaction with sex was statistically significant (p = 0.007; F(1,81) = 7.756; ηp 2 = 0.087) and higher left hemidiaphragm thickness at Tins was predicted by the BFB + IMT group (R 2 = 0.099; β = 0.050; F(1,82) = 8.997; p = 0.004) and male sex (R 2 = 0.079; β = 0.045; F(1,81) = 7.756;p = 0.007). Furthermore, greater left hemidiaphragm thickness at Tins-exp was predicted by younger age (R 2 = 0.052; β = -0.001; F(1,82) = 4.540; p = 0.036). Discussion: The simultaneous bilateral visual diaphragm biofeedback by ultrasonography in conjunction with IMT was effective in both increasing the left diaphragmatic thickness during inspiration, which was positively influenced and predicted by male sex and younger age, and increasing the bilateral PPT of the paraspinal muscles in patients with NSLBP.

Investigating the associations between lumbar paraspinal muscle health and age, BMI, sex, physical activity, and back pain using an automated computer-vision model: a UK Biobank study

BACKGROUND CONTEXT

The role of lumbar paraspinal muscle health in back pain (BP) is not straightforward. Challenges in this field have included the lack of tools and large, heterogenous datasets to interrogate the association between muscle health and BP. Computer-vision models have been transformative in this space, enabling the automated quantification of muscle health and the processing of large datasets.

PURPOSE

To investigate the associations between lumbar paraspinal muscle health and age, sex, BMI, physical activity, and BP in a large, heterogenous dataset using an automated computer-vision model.

DESIGN

Cross-sectional study.

PATIENT SAMPLE

Participants from the UK Biobank with abdominal Dixon fat-water MRI (N=9,564) were included (41.8% women, mean [SD] age: 63.5 [7.6] years, BMI: 26.4 [4.1] kg/m2) of whom 6,953 reported no pain, 930 acute BP, and 1,681 chronic BP.

OUTCOME MEASURES

Intramuscular fat (IMF) and average cross-sectional area (aCSA) were automatically derived using a computer-vision model for the left and right lumbar multifidus (LM), erector spinae (ES), and psoas major (PM) from the L1 to L5 vertebral levels.

METHODS

Two-tailed partial Pearson correlations were generated for each muscle to assess the relationships between the muscle measures (IMF and aCSA) and age (controlling for BMI, sex, and physical activity), BMI (controlling for age, sex, and physical activity), and physical activity (controlling for age, sex, and BMI). One-way ANCOVA was used to identify sex differences in IMF and aCSA for each muscle while controlling for age, BMI, and physical activity. Similarly, one-way ANCOVA was used to identify between-group differences (no pain, acute BP, and chronic BP) for each muscle and along the superior-inferior expanse of the lumbar spine while controlling for age, BMI, sex, and physical activity (α=0.05).

RESULTS

Females had higher IMF (LM mean difference [MD]=11.1%, ES MD=10.2%, PM MD=0.3%, p<.001) and lower aCSA (LM MD=47.6 mm2, ES MD=350.0 mm2, PM MD=321.5 mm2, p<.001) for all muscles. Higher age was associated with higher IMF and lower aCSA for all muscles (r≥0.232, p<.001) except for LM and aCSA (r≤0.013, p≥.267). Higher BMI was associated with higher IMF and aCSA for all muscles (r≥0.174, p<.001). Higher physical activity was associated with lower IMF and higher aCSA for all muscles (r≥0.036, p≤.002) except for LM and aCSA (r≤0.010, p≥.405). People with chronic BP had higher IMF and lower aCSA than people with no pain (IMF MD≤1.6%, aCSA MD≤27.4 mm2, p<.001) and higher IMF compared to acute BP (IMF MD≤1.1%, p≤.044). The differences between people with BP and people with no pain were not spatially localized to the inferior lumbar levels but broadly distributed across the lumbar spine.

CONCLUSIONS

Paraspinal muscle health is associated with age, BMI, sex, and physical activity with the exception of the association between LM aCSA and age and physical activity. People with BP (chronic>acute) have higher IMF and lower aCSA than people reporting no pain. The differences were not localized but broadly distributed across the lumbar spine. When interpreting measures of paraspinal muscle health in the research or clinical setting, the associations with age, BMI, sex, and physical activity should be considered.

Graph modeling of relational structures among functioning variables with low back pain: an exploratory analysis based on International Classification of Functioning, Disability and Health

BACKGROUND

Given the complex etiology, multidimensional impact, and widespread prevalence of low back pain (LBP), it is crucial to prioritize intervention targets based on understanding the relationships between functional impairments in patients. This prioritization maximizes the physical and psychological benefits for patients, and graph modeling holds promise in achieving these objectives.

AIM

The aim of this study was establishing a graphical model of functioning variables for LBP based on the International Classification of Functioning, Disability, and Health (ICF) to identify the most influential items (i.e., functioning variables) on the physical and mental well-being of patients. Exploring feasible intervention measures by understanding the dysfunction correlations among these variables.

DESIGN

Cross-sectional survey.

SETTING

Nine hospitals in Jiangsu Province, China.

POPULATION

Three hundred and six persons with LBP aged ≥18 years.

METHODS

All patients were assessed using the Comprehensive ICF Core Sets for LBP. The scoring system was converted to dichotomous data, with 1 indicating dysfunction and 0 indicating no dysfunction. In the graphical model, network parameters and the results of Item Response Theory modeling (as detailed in our other article) were used to determine the importance of items, while partial correlations were utilized to estimate the dysfunction correlations between functioning variables.

RESULTS

1) A total of 56 ICF items were located in the backbone structure of LBP, among which d430 (Lifting and carrying objects) occupied the most central position, followed by b126 (Temperament and personality functions). 2) In the main component of backbone structure, d430 has moderate dysfunction correlation with looking after one's health (0.6027), social norms, practices and ideologies (0.597), stability of joint functions (0.5759), and emotional functions (0.4078). b126 has moderate dysfunction correlation with basic interpersonal interactions (0.6595).

CONCLUSIONS

d430 and b126 significantly impact the physical and mental well-being of LBP patients. To improve d430, maintaining exercise habits, reducing working hours, enhancing lumbar stability, and overcoming fear-related emotions are recommended. Similarly, improving b126 can be achieved through enhancing interpersonal relationships.

CLINICAL REHABILITATION IMPACT

Through the identification of crucial functioning variables and the associated dysfunctional correlation relationships, graphical model of Comprehensive ICF Core Set for LBP can offer healthcare decision-makers valuable insights into potential treatment targets and pathways aimed at improving the condition of LBP patients.

Group Physical Therapy Programs for Military Members With Musculoskeletal Disorders: A Pragmatic Randomized Controlled Trial

OBJECTIVE: To compare the effects of personalized, supervised group-based programs (ie, group physical therapy programs) and usual one-on-one physical therapy care (ie, usual physical therapy care) on disability for military personnel suffering from low back pain, rotator cuff-related shoulder pain, patellofemoral pain syndrome, or lateral ankle sprain. Secondary outcomes were pain severity, pain-related fear, health-related quality of life, and patients' satisfaction with their condition and care. DESIGN: Non-inferiority pragmatic randomized clinical trial. METHODS: One hundred twenty military personnel from the Canadian Armed Forces, experiencing 1 of 4 targeted musculoskeletal disorders, were consecutively recruited and randomly assigned to group physical therapy programs or usual physical therapy care. Disability, pain severity, pain-related fear, and health-related quality-of-life outcomes were measured at 6, 12, and 26 weeks after baseline. Satisfaction with treatment was evaluated at the end of the intervention. Intention-to-treat analyses using linear mixed models with random effects were used to compare the effects of interventions. Chi-square tests were used to compare satisfaction. RESULTS: There were no significant Time × Group interactions for any of the primary and secondary outcomes (Time × Group: P>.67). Satisfaction with treatment also did not differ between groups (P>.05). Statistically significant and clinically important improvements were observed in both groups for all outcomes after 12 weeks (Time effect: P<.01), except for health-related quality of life (P = .13). CONCLUSION: Group physical therapy programs were not inferior to usual physical therapy care for managing pain, functional capacity, and patients' satisfaction with care of military personnel presenting with various musculoskeletal disorders. Both interventions led to clinical and statistical improvement in pain and function in the mid and long term. Group physical therapy could be an effective strategy to enhance access to care. J Orthop Sports Phys Ther 2024;54(6):1-10. Epub 26 Mar 2024. doi:10.2519/jospt.2024.12342.

Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background

Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development.

Methods

We searched PubMed, PEDro and Embase for articles published in English up to May 3 rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies.

Results

We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use.

Conclusions

This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design

INTRODUCTION AND PURPOSE

Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules.

RESULTS

After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration.

DISCUSSION

The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up.

CONCLUSION

CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

Quantifying lumbar paraspinal intramuscular fat: Accuracy and reliability of automated thresholding models

Background

The reported level of lumbar paraspinal intramuscular fat (IMF) in people with low back pain (LBP) varies considerably across studies using conventional T1- and T2-weighted magnetic resonance imaging (MRI) sequences. This may be due to the different thresholding models employed to quantify IMF. In this study we investigated the accuracy and reliability of established (two-component) and novel (three-component) thresholding models to measure lumbar paraspinal IMF from T2-weighted MRI.

Methods

In this cross-sectional study, we included MRI scans from 30 people with LBP (50% female; mean (SD) age: 46.3 (15.0) years). Gaussian mixture modelling (GMM) and K-means clustering were used to quantify IMF bilaterally from the lumbar multifidus, erector spinae, and psoas major using two and three-component thresholding approaches (GMM2C; K-means2C; GMM3C; and K-means3C). Dixon fat-water MRI was used as the reference for IMF. Accuracy was measured using Bland-Altman analyses, and reliability was measured using ICC3,1. The mean absolute error between thresholding models was compared using repeated-measures ANOVA and post-hoc paired sample t-tests (α = 0.05).

Results

We found poor reliability for K-means2C (ICC3,1 ≤ 0.38), moderate to good reliability for K-means3C (ICC3,1 ≥ 0.68), moderate reliability for GMM2C (ICC3,1 ≥ 0.63) and good reliability for GMM3C (ICC3,1 ≥ 0.77). The GMM (p < .001) and three-component models (p < .001) had smaller mean absolute errors than K-means and two-component models, respectively. None of the investigated models adequately quantified IMF for psoas major (ICC3,1 ≤ 0.01).

Conclusions

The performance of automated thresholding models is strongly dependent on the choice of algorithms, number of components, and muscle assessed. Compared to Dixon MRI, the GMM performed better than K-means and three-component performed better than two-component models for quantifying lumbar multifidus and erector spinae IMF. None of the investigated models accurately quantified IMF for psoas major. Future research is needed to investigate the performance of thresholding models in a more heterogeneous clinical dataset and across different sites and vendors.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Understanding how therapeutic exercise prescription changes outcomes important to patients with persistent non-specific low back pain: a realist review protocol

INTRODUCTION

Persistent low back pain (LBP) is the leading cause of disability worldwide, and therapeutic exercise is recommended as a first-line treatment in international guidelines. The effects of exercise on clinical outcomes of pain and physical function are small to moderate, despite broader impacts on cardiovascular systems, biological health, mood, and emotional well-being. Therapeutic exercise prescription is defined as exercise that is prescribed by a clinician for a health-related treatment. It is unknown how therapeutic exercise prescription creates effects on outcomes of importance. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain situations, settings, or populations to create an intended or unintended outcome (O). Our objective is to explore and understand the mechanisms by which therapeutic exercise prescription changes outcomes for people with persistent LBP.

METHODS

We will develop initial programme theories based on preliminary data from a previous systematic review and consensus workshop. These theories will be modified with input from a steering group (experts), a stakeholder group (people with lived experience of exercise for persistent LBP and clinicians), and a scoping search of the published literature. An information specialist will design and undertake an iterative search strategy. These will be used to create CMO configurations, which will be refined and tested using the literature. The realist review will be reported following RAMESES guidance.

DISCUSSION

Realist reviews are uncommon in LBP research to date, yet those offer an opportunity to contrast with traditional methods of randomised controlled trials and systematic reviews and provide additional information regarding the contexts and mechanisms that may trigger certain outcomes. This can aid our understanding of the contextual features that may influence exercise prescription, such as for whom they are most effective, in what setting, how they are implemented and why. This realist synthesis will enhance our understanding of therapeutic exercise prescription to improve adherence and engagement and ultimately will provide clinically relevant recommendations regarding exercise prescription for those with persistent LBP.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (CRD42017072023).

Strong Association of Depression and Anxiety With the Presence of Back Pain While Impact of Spinal Imaging Findings is Limited: Analysis of an MRI Cohort Study

Development of back pain is multifactorial, and it is not well understood which factors are the main drivers of the disease. We therefore applied a machine-learning approach to an existing large cohort study data set and sought to identify and rank the most important contributors to the presence of back pain amongst the documented parameters of the cohort. Data from 399 participants in the KORA-MRI (Cooperative health research in the region Augsburg-magnetic resonance imaging) (Cooperative Health Research in the Region Augsburg) study was analyzed. The data set included MRI images of the whole body, including the spine, metabolic, sociodemographic, anthropometric, and cardiovascular data. The presence of back pain was one of the documented items in this data set. Applying a machine-learning approach to this preexisting data set, we sought to identify the variables that were most strongly associated with back pain. Mediation analysis was performed to evaluate the underlying mechanisms of the identified associations. We found that depression and anxiety were the 2 most selected predictors for back pain in our model. Additionally, body mass index, spinal canal width and disc generation, medium and heavy physical work as well as cardiovascular factors were among the top 10 most selected predictors. Using mediation analysis, we found that the effects of anxiety and depression on the presence of back pain were mainly direct effects that were not mediated by spinal imaging. In summary, we found that psychological factors were the most important predictors of back pain in our cohort. This supports the notion that back pain should be treated in a personalized multidimensional framework. PERSPECTIVE: This article presents a wholistic approach to the problem of back pain. We found that depression and anxiety were the top predictors of back pain in our cohort. This strengthens the case for a multidimensional treatment approach to back pain, possibly with a special emphasis on psychological factors.

LOW BACK PAIN ESTIMATES IN PROFESSIONAL SOCCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective

To evaluate the epidemiological and clinical characteristics of low back pain (LBP) in adult professional soccer players.

Methods

Systematic review and meta-analysis.

Results

The review included 44 studies. The pooled prevalence of LBP during ≤ 1 season was 1% (95%CI = 0-4%) in men. The pooled point prevalence of LBP was 25% (95%CI = 16-36%) in men and 28% (95%CI = 20-37%) in women. The pooled past-year prevalence of LBP was 34% (95%CI = 24-44%) in men. The pooled lifetime prevalence of LBP was 32% (95%CI = 25-39%) in men and 50% (95%CI = 32-69%) in women. The pooled frequency of LBP/total number of injuries was 2% (95%CI = 1-3%) in men and 4% (95%CI = 2-5%) in women. The pooled incidence rate of LBP/1,000 player-hours of exposure was 0.30 (95%CI = 0.17- 0.53) in men and 0.32 (95%CI = 0.06 -1.87) in women. The recurrence of LBP ranged from 3% to 63% in men. The intensity of LBP ranged from 1.68 (2.39) to 4.87 (2.14) points on a 0-10 scale (minimum = 0 and maximum = 8 points). The severity of LBP (days absent from professional activities due to pain) ranged from 2 (0) to 10 (19) days (minimum = 1 and maximum = 28 days).

Conclusion

Adult elite soccer players have a substantial prevalence of LBP. The frequency and incidence of LBP (compared with other conditions and sports) seems to be low. Estimates of the recurrence, intensity, and severity of LBP are uncertain. Level of Evidence II, Systematic Review of Level II Studies.

Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain

PURPOSE

Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF.

METHODS

Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes.

RESULTS

Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients.

CONCLUSION

The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.

A Qualitative Investigation of the Psychosocial Impact of Chronic Low Back Pain in Ghana

INTRODUCTION

Chronic low back pain (CLBP) is a global health concern associated with multidimensional/biopsychosocial levels of affectation in developed countries, with holistic management requiring consideration of these factors. There has been minimal research exploring the psychosocial impact of CLBP, and the factors influencing it, in African contexts, with none in Ghana.

OBJECTIVES

To explore the psychosocial impact of CLBP among patients with CLBP in Ghana.

DESIGN

Qualitative study using individual semistructured face-to-face interviews, underpinned by Straussian grounded theory principles and critical realist philosophy.

PARTICIPANTS

Thirty patients with CLBP attending physiotherapy at two hospitals in Ghana.

RESULTS

Five categories: loss of self and roles, emotional distress, fear, stigmatisation and marginalisation, financial burden, and social support and three mechanisms: acquired biomedical/mechanical beliefs from healthcare professionals (HCPs), sociocultural beliefs and the socioeconomic impact of CLBP were derived.

CONCLUSION

CLBP adversely affects multidimensional/biopsychosocial aspects of individuals experiencing CLBP in Ghana. This delineates the need for a biopsychosocial approach to care. There is the need for HCPs in Ghana to reassess current CLBP management strategies to address the influence of adverse HCPs biomedical inclinations on patients' psychosocial consequences. Population-based education strategies and consideration of formal support systems for persons with disabling CLBP may also be beneficial.

Pain catastrophising and kinesiophobia mediate pain and physical function improvements with Pilates exercise in chronic low back pain: a mediation analysis of a randomised controlled trial

QUESTION

How much are the reductions in pain intensity and improvements in physical function from Pilates exercise mediated by changes in pain catastrophising and kinesiophobia?

DESIGN

This was a secondary causal mediation analysis of a four-arm randomised controlled trial testing Pilates exercise dosage (once, twice or thrice per week) against a booklet control.

PARTICIPANTS

Two hundred and fifty-five people with chronic low back pain.

DATA ANALYSIS

All analyses were conducted in R software (version 4.1.2) following a preregistered analysis plan. A directed acyclic graph was constructed to identify potential pre-treatment mediator-outcome confounders. For each mediator model, we estimated the intervention-mediator effect, the mediator-outcome effect, the total natural indirect effect (TNIE), the pure natural direct effect (PNDE), and the total effect (TE).

RESULTS

Pain catastrophising mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.21, 95% CI -0.47 to -0.03) and physical function (TNIE MD -0.64, 95% CI -1.20 to -0.18). Kinesiophobia mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.31, 95% CI -0.68 to -0.02) and physical function (TNIE MD -1.06, 95% CI -1.70 to -0.49). The proportion mediated by each mediator was moderate (21 to 55%).

CONCLUSION

Reductions in pain catastrophising and kinesiophobia partially mediated the pathway to improved pain intensity and physical function when using Pilates exercise for chronic low back pain. These psychological components may be important treatment targets for clinicians and researchers to consider when prescribing exercise for chronic low back pain.

Machines, journeys, prisons and yo-yos: Metaphors of pain, illness and medicine in consultations with chronic pain patients

INTRODUCTION

This paper examines pain, illness and medicine metaphors as used in consultations between chronic pain patients and anaesthesiologists, physiotherapists and psychologists in a Belgian pain clinic. As metaphors frame and highlight aspects of understanding and experiences of life events, including illness, they can provide insight in how health professionals and patients construct illness, pain and medicine in interaction.

MATERIALS AND METHOD

16 intake consultations (collected in Belgium in April-May 2019) between 6 patients and 4 health professionals were qualitatively coded twice ATLAS. TI by a team of 3 coders, using an adjusted form of the Metaphor Identification Procedure. Each metaphor was labelled for source domain, target domain and speaker.

RESULTS

A number of metaphors that have been previously documented in past research were frequent in our data too, such as journey and machine metaphors, although sometimes also used differently, like war metaphors. Our data set also contained many few-used and sometimes more novel metaphors, such as ILLNESS IS A YO-YO. Many metaphors highlight particular aspects of living with and talking about chronic pain, such as its duration and persistent presence, a lack of agency and feelings of powerlessness, and a dualistic perspective on body and mind.

DISCUSSION AND CONCLUSION

The metaphors used by health professionals and patients give insight in the lived experience of having and treating chronic pain. In this way, they can contribute to our understanding of patients' experiences and challenges, how they recur in clinical communication, and how they are related to wider discourses on health, illness and pain.

Expressed Beliefs about the Cause of Pain in a Pediatric Population: A Qualitative Study

(1) Background: The aims of this study are to explore what beliefs children and adolescents manifest about the cause of the pain they describe, to compare whether there are differences between beliefs by age and the persistence of pain, and to relate the explanations of the cause of pain with current scientific evidence. (2) Methods: a cross-sectional qualitative study was used. The primary endpoint of the study was obtaining explanations of the cause of pain recorded by means of an open-ended question. The participants were school-age children attending a charted school in the province of Barcelona. (3) Results: The children and adolescents proposed a diverse range of explanations for the cause of pain that they reported in their responses. The most frequent explanation for the cause of pain were pathologies and injuries (45.95%), ergonomic issues (22.60%) and psychological issues (15.95%). (4) Conclusions: There is a lot of variety in the explanations that young people give about the cause of their pain in schoolchildren aged between 10 and 16 years old. There exists a high prevalence of explanations non-associated with tissue damage (ENAD) concerning the causes of pain described. It is necessary that future health prevention programs dedicated to early ages consider which beliefs about the cause of pain are the most frequent in the pediatric population.

Is fatty infiltration in paraspinal muscles reversible with exercise in people with low back pain? A systematic review

PURPOSE

Increased fatty infiltration in paraspinal muscles has been recognized as a feature of muscle quality loss in people with Low Back Pain (LBP) and is highly associated with the severity of LBP and dysfunction. Reducing fatty infiltration has been recognized as a rehabilitation aim. An earlier systematic review published in 2014 revealed conflicting evidence for the reversibility of paraspinal muscle quality by means of exercise and no updates have been published since. A new systematic literature search is warranted.

METHOD

Pubmed, CINAHL and Embase were searched from inception to July 2022. Randomized, non-randomized controlled trials (RCT and non-RCT) and single-arm trials were included if they reported the effect of exercise on paraspinal fatty infiltration in people with LBP. Effect sizes and statistical power were calculated for (1) exercise versus control, and (2) pre-post exercise changes. Available data from the RCTs were pooled via meta-analysis when appropriate. Otherwise, data were synthesized qualitatively.

RESULTS

Two RCTs, one non-RCT and three single-arm trials met the selection criteria. Data were not pooled due to substantial clinical heterogeneity. Effect sizes from the RCTs revealed no significant difference for exercise versus control. One single-arm trial with high risk of bias demonstrated a significant pre-post difference with moderate effect size, but only at one (T12-L1) of the investigated levels.

CONCLUSION

Moderate quality evidence is available that paraspinal fatty infiltration is not reversible with exercise in people with LBP. More larger RCT's are needed to draw firmer conclusions.

Clarification of the "pain neuroscience education" concept in the management of patients with persistent low back pain: A scoping review

BACKGROUND

Patient education is a recommended treatment strategy for persistent low back pain (PLBP). Pain neuroscience education (PNE) is an emerging concept with boundaries still unclear.

OBJECTIVE

To clarify the PNE concept and identify its key characteristics in PLBP management.

METHODS

A systematic search was conducted using the following databases: Pubmed, ScienceDirect, Google Scholar, Cochrane, and Pedro.

INCLUSION CRITERIA

publications in English or French on pain neuroscience education and chronic low back pain, educational books cited in white literature. Three reviewers independently selected eligible studies for final inclusion. Numerical analysis and narrative synthesis were carried out from the extracted data.

RESULTS

From 919 identified publications, 54 were selected. Ten educational resources were added. PNE refers to a theoretical framework, a specific educational intervention, and an overall care approach. It is characterized by the intention to help the patient reconceptualize their PLBP from a tissue injury marker to a protective, neurobiological perspective, and then to increase adherence to biopsychosocial rehabilitation and normalize cognitive-behavioral responses. Pain sciences concepts are presented with an optimization of learning strategies.

CONCLUSION

PNE stands out from other educational and cognitive behavioral approaches through its objective of changing the pain concept.

What You Need to Know About Sacroiliac Dysfunction

Low back pain is the leading cause of disability worldwide, and sacroiliac dysfunction is estimated to occur in 15%-30% of those with nonspecific low back pain. Nurses are in the unique position to support and provide education to patients who may be experiencing sacroiliac dysfunction or possibly apply this knowledge to themselves, as low back pain is a significant problem experienced by nurses. A patient's clinical presentation, including pain patterns and characteristics, functional limitations, common etiologies and musculoskeletal system involvement, current diagnostic tools, and realm of treatments, are discussed along with their respective efficacy. Distinction is made between specific diagnosis and treatment of joint involvement and that of sacroiliac regional pain, as well as other factors that play a role in diagnosis and treatment for the reader's consideration.

Cross-Cultural Adaptation, Reliability, and Validity of a Hebrew Version of the Physiotherapist Self-Efficacy Questionnaire Adjusted to Low Back Pain Treatment

BACKGROUND

Clinician self-efficacy may be an important factor in the success of treatment for low back pain (LBP), which has unique clinical features and a high prevalence rate. Therefore, it is important to assess clinicians' self-efficacy in this particular condition. The Physiotherapist Self-Efficacy (PSE) questionnaire was designed to measure self-efficacy of physiotherapy students.

OBJECTIVES

To translate and trans-culturally adapt the PSE into Hebrew, to adjust the questionnaire to assess clinicians' self-efficacy in the treatment of LBP, and to assess the construct validity and reliability of the PSE in the Hebrew version.

METHODS

After adjustment for LBP and cross-cultural adaptation, test-retest reliability was assessed with 140 physiotherapists. The analyses used included exploratory factor analysis for structural validity, Cronbach's alpha for internal consistency, and intraclass correlation coefficients (ICC) for test-retest reliability.

RESULTS

Factor analysis revealed a unidimensional structure with an acceptable model fit. The PSE translated into Hebrew exhibited a very high internal consistency (α = 0.93) and excellent test-retest reliability (ICC = 0.94). The standard error of measurement (SEM) and minimal detectable change (MDC) were 1.75 and 4.85, respectively.

CONCLUSIONS

The Hebrew-translated PSE showed adequate validity and excellent reliability, indicating its suitability to measure clinician self-efficacy in treating patients with LBP.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain

BACKGROUND

Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes and how it relates to quantitative changes.

METHODS

A mixed method study in the context of an existing single-case design involving 12 people with disabling non-specific LBP. Interviews were conducted before and after a 12-week physiotherapy-led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualized, quantitative measures of movement, posture, psychological factors, pain and activity limitation.

RESULTS

Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterized the embodiment of 'nonconscious protection', while healthcare and societal messages prompted pain-related fear and 'conscious protection'. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention ('conscious non-protection'), but most returned to automatic, normal and fearless patterns ('nonconscious non-protection'), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures and less back muscle EMG accompanied positive changes in self-report factors.

CONCLUSION

The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non-specific LBP. This involved a re-conceptualisation of movement and posture, from threatening, to therapeutic.

SIGNIFICANCE

Findings from qualitative interviews before and after a Cognitive Functional Therapy intervention in 12 people with disabling low back pain highlighted an individualized recovery journey from conscious and nonconscious protection to conscious non-protection for some, and nonconscious non-protection for many. Pre and post-quantitative measures of movement, posture, psychological factors, pain and activity limitation integrated well with the qualitative findings. The findings suggest movement and posture may form part of a multidimensional pain schema.

The effectiveness of post-professional physical therapist training in the treatment of chronic low back pain using a propensity score approach with machine learning

RATIONALE

Low back pain (LBP) is a leading cause of disability in the United States creating substantial hardships through negative social, financial, and health effects. Chronic low back pain (CLBP) accounted for above half of patients treated in physical therapy (PT) clinics for LBP. However, research shows small benefit from PT in CLBP treatment. Preliminary evidence suggests clinician-level training variables may affect outcomes, but requires further investigation to determine whether patients with CLBP benefit from treatment by providers with post-professional training. This study examined the relationship between clinician training levels and patient-reported outcomes in CLBP treatment.

METHODS

Physical therapies were surveyed using a large patient outcome assessment system to determine and categorise them by level of post-professional education. To account for the possibility that clinicians with higher levels of training are referred more-complex patients, a machine learning approach was used to identify predictive variables for clinician group, then to construct propensity scores to account for differences between groups. Differences in functional status score change among pooled data were analysed using linear models adjusted for propensity scores.

RESULTS

There were no clinically meaningful differences in patient outcomes when comparing clinician post-professional training level. The propensity score method proved to be a valuable way to account for differences at baseline between groups.

CONCLUSION

Post-professional training does not appear to contribute to improved patient outcomes in the treatment of CLBP. This study demonstrates that propensity score analysis can be used to ensure that differences observed are true and not due to differences at baseline.

Convolutional neural networks for the automatic segmentation of lumbar paraspinal muscles in people with low back pain

The size, shape, and composition of paraspinal muscles have been widely reported in disorders of the cervical and lumbar spine. Measures of size, shape, and composition have required time-consuming and rater-dependent manual segmentation techniques. Convolutional neural networks (CNNs) provide alternate timesaving, state-of-the-art performance measures, which could realise clinical translation. Here we trained a CNN for the automatic segmentation of lumbar paraspinal muscles and determined the impact of CNN architecture and training choices on segmentation performance. T₂-weighted MRI axial images from 76 participants (46 female; age (SD): 45.6 (12.8) years) with low back pain were used to train CNN models to segment the multifidus, erector spinae, and psoas major muscles (left and right segmented separately). Using cross-validation, we compared 2D and 3D CNNs with and without data augmentation. Segmentation accuracy was compared between the models using the Sørensen-Dice index as the primary outcome measure. The effect of increasing network depth on segmentation accuracy was also investigated. Each model showed high segmentation accuracy (Sørensen-Dice index ≥ 0.885) and excellent reliability (ICC_2,1 ≥ 0.941). Overall, across all muscles, 2D models performed better than 3D models (p = 0.012), and training without data augmentation outperformed training with data augmentation (p < 0.001). The 2D model trained without data augmentation demonstrated the highest average segmentation accuracy. Increasing network depth did not improve accuracy (p = 0.771). All trained CNN models demonstrated high accuracy and excellent reliability for segmenting lumbar paraspinal muscles. CNNs can be used to efficiently and accurately extract measures of paraspinal muscle health from MRI.

Getting in touch: Communication in physical therapy practice and the multiple functions of language

In physical therapy, communication that actively involves the patient is seen as the foundation of patient-centered treatment. Research on communication in physical therapy highlights how patients' opportunity to actively participate is often limited by the therapists' focus on biomedical facts and clinical tasks. Few studies have explored aspects of communication in clinical practice that may promote patients' active participation. The aim of this study is to shed light on verbal and nonverbal communication used by physical therapists to get in touch with patients and how this physical and linguistic touching may contribute to encouraging patients' participation. The selected case is from a qualitative observational case study of the first encounter between a female physical therapist and a male patient with chronic neck pain. Drawing on theories about communication and the metafunctions of language, the findings highlight how the therapist's use of unfinished sentences, repetitions of the patient's own words, touch, gaze and accepting interruptions from the patient promotes the patient's participation. Demonstrations of the use of linguistic communication theory in this study may contribute to enhancing physical therapists' self-awareness around communication and how to get in touch with patients, which is a fundamental element in patient-centered treatment.

"I don't want to be a burden" A qualitative study of the beliefs of women with chronic low back pain in relation to their painful experience

BACKGROUND

Women's pain is still poorly understood. Moreover, maladaptive pain beliefs contribute to the disability associated with low back pain and play a key role in the transition from acute to chronic symptoms.

OBJECTIVES

To explore the beliefs of women with non-specific chronic low back pain in terms of nature of symptoms, fears associated with pain, expectations for recovery, family, social and work-related limitations, and perceived self-efficacy.

DESIGN AND METHODS

A qualitative study with an interpretative approach was undertaken. Face-to-face, semi-structured individual interviews were performed. Study participants were 10 women with non-specific chronic low back pain living in the Metropolitan Region of Chile. Thematic analysis was used to analyze the data. A deductive process was used to code the text and categorize the data.

RESULTS

Participants described maladaptive beliefs about pain, leading to fearful attitudes and low expectations for recovery. These beliefs seemed to perpetuate pain and limit engagement in daily tasks and meaningful activities. Some of these beliefs were associated with information provided by healthcare professions. Despite having maladaptive beliefs, women perceived themselves as self-effective.

CONCLUSION

Women with chronic low back pain described a range of different pain beliefs across a complex categorial structure. The contents of such structure may interfere with their decisions about therapeutic options. Their beliefs were often ungrounded in scientific principles, even if the information may have been provided by healthcare providers. Physical therapists would benefit from these findings to improve communication with their patients and assess the role of beliefs in decision-making.

Group-based exercice training programs for military members presenting musculoskeletal disorders - protocol for a pragmatic randomized controlled trial

BACKGROUND

Musculoskeletal disorders are a leading cause of morbidity and the most prevalent source of disability among soldiers. Their high prevalence in armed forces and limited ressources have led to problems related to access to physical rehabilitation care. To increase access, supervised group-based exercise programs for the most prevalent musculoskeletal disorders (low back pain, patellofemoral pain, rotator cuff-related shoulder pain or lateral ankle sprain) have been developed at a Canadian Armed forces (CAF) base, but their effectiveness has not been evaluated. The primary objective of this randomized controlled trial is to evaluate the mid- and long-term effects of these group-based training programs on pain severity and functional limitations, in comparison with usual individual physiotherapy care. Secondary objectives include comparing both interventions in terms of health-related quality of life, pain-related fear, and patients' satisfaction.

METHODS

One hundred and twenty soldiers with a new medical referral for physiotherapy services for one of the four targeted musculoskeletal disorders will be consecutively recruited. They will be randomly assigned to either group-based training program or usual individual physiotherapy care, and will take part in the assigned 12-week intervention. There will be four evaluation sessions over 26 weeks (baseline, week 6, 12 and 26). At each follow-up, functional limitations, pain severity, health-related quality of life and pain-related fears will be assessed. Patients satisfaction with treatment will also be evaluated at the end of the intervention period. Either two-way repeated measures ANOVA will be used to analyse and compare the effects of the interventions.

DISCUSSION

This RCT will determine the effectiveness of group-based training programs compared to usual individual physiotherapy care. This new intervention model could represent an efficient, and more pro-active approach to manage a higher number of soldiers with musculoskeletal disorders. It could improve access to physical rehabilitation care and improve the health of soldiers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT05235152 ), February 11th 2022.

Impact of Work-Related Chronic Low Back Pain on Functional Performance and Physical Capabilities in Women and Men: A Sex-Wise Comparative Study

Purpose

This study is aimed at determining the impact of work-related low back pain (LBP) on functional performance and physical capabilities.

Methods

This cross-sectional study included women (n = 25, mean age, 38.12 ± 4.59) and men (n = 25, mean age, 37.20 ± 5.38) with a history of work-related mechanical chronic LBP who visited our university hospital's outpatient department. All participants were assessed for primary outcomes, including the severity of LBP on rest and on activity, functional performance, and physical capabilities using a numeric pain rating scale (NPRS), Roland-Morris disability questionnaire (RDQ), five-time sit-to-stand test (FTSST), and fifty-foot walk test (FFWT), respectively. Independent t-tests compared the scores of the outcomes between groups while Pearson's correlation coefficient identified the correlation between the outcomes' measures at a significance level of 0.05.

Results

With a response rate of 63.29%, a total of fifty participant's data were obtained for the analysis. A comparison between women and men groups highlighted a significant difference in the scores of the FTSST and FFWT; however, there were insignificant differences in the scores of the NPRS at rest, NPRS on activity, and RDQ. The bivariate correlation revealed a highly significant, positive, and moderate correlation between the scores of NPRS at rest and FTSST, NPRS on activity and FTSST, NPRS at rest and FFWT, NPRS on activity and FFWT, FTSST and RDQ, and FFWT and RDQ in the women group. Similarly, there was a significant, positive, and low correlation between the scores of FTSST and RDQ and FFWT and RDQ in the men group.

Conclusion

Work-related chronic LBP affected the physical capabilities of women more than those of men. However, it equally affected the functional performance of all participants in the study. Furthermore, work-related chronic LBP affected the physical capabilities (FTSST and FFWT) and functional performance (RDQ) of women more than those of men.

Illness perceptions; exploring mediators and/or moderators in disabling persistent low back pain. Multiple baseline single-case experimental design

INTRODUCTION

Illness Perceptions (IPs) may play a role in the management of persistent low back pain. The mediation and/or moderation effect of IPs on primary outcomes in physiotherapy treatment is unknown.

METHODS

A multiple single-case experimental design, using a matched care physiotherapy intervention, with three phases (phases A-B-A') was used including a 3 month follow up (phase A'). Primary outcomes: pain intensity, physical functioning and pain interference in daily life. Analyzes: linear mixed models, adjusted for fear of movement, catastrophizing, avoidance, sombreness and sleep.

RESULTS

Nine patients were included by six different primary care physiotherapists. Repeated measures on 196 data points showed that IPs Consequences, Personal control, Identity, Concern and Emotional response had a mediation effect on all three primary outcomes. The IP Personal control acted as a moderator for all primary outcomes, with clinically relevant improvements at 3 month follow up.

CONCLUSION

Our study might indicate that some IPs have a mediating or a moderating effect on the outcome of a matched care physiotherapy treatment. Assessing Personal control at baseline, as a relevant moderator for the outcome prognosis of successful physiotherapy management of persistent low back pain, should be further eplored.

The relationship between psychosocial factors and reported disability: the role of pain self-efficacy

BACKGROUND

Chronic pain and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is now considered a world level crisis. Chronic non-specific low back pain (CNLBP) contributes a significant proportion to the chronic pain population. CNLBP occurs with overlapping psychosocial factors. This study was design to investigate specific psychosocial factors and their influence on reported disability in a population with CNLBP.

METHODS

The specific psychosocial factors examined included fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study investigated the mediating role between pain self-efficacy, the specific psychosocial factors, and reported disability. The study recruited 61 female and 29 male participants from physical therapy clinics. The participants were between 20-to-60 years of age and diagnosed with CNLBP. All participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index. The battery of questionnaires measured fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability. Multivariate regression and mediation analyses was used to analyse the data.

RESULTS

The principal finding was a strong inverse relationship between pain self-efficacy and reported disability with a p-value < 0.001. Further, pain self-efficacy was considered a statistical mediator with consistent p-value < 0.001 for the specific psychosocial factors investigated within this data set. Pain self-efficacy was considered to have a mediating role between reported fear of physical activity and disability, reported pain catastrophizing and disability, and reported depression and disability. Additionally, age and reported pain levels proved to be statistically significant. Adjustments for age and pain level did not alter the role of pain self-efficacy.

CONCLUSION

The results identified a mediating role for pain self-efficacy between the specific psychosocial factors (fear, catastrophizing, and depression) and reported disability. Pain self-efficacy plays a more significant role in the relationships between these specific psychosocial factors and reported disability with CNLBP than previously considered.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evidence-Based Practice for Non-Specific Low Back Pain: Canadian Physiotherapists' Adherence, Beliefs, and Perspectives

Purpose: Physiotherapists are key providers of care for patients with low back pain (LBP); however, information on Canadian physiotherapists' use of evidence-based clinical practice guidelines (EBCPGs) for LBP is lacking. We aimed to (1) describe Canadian physiotherapists' adherence to EBCPGs for LBP; (2) compare beliefs and attitudes of physiotherapists with higher and lower adherence; (3) identify predictors of adherence; and (4) gather physiotherapists' perceptions about the care provided to patients with LBP. Method: This mixed methods study involved two phases: (1) a survey containing a LBP clinical scenario and (2) qualitative semi-structured interviews with physiotherapists. Results: A total of 406 (77%) of the 525 survey respondents demonstrated higher adherence (score of 3 or 4) to EBCPGs; however, only 29.5% chose interventions to address psychosocial issues. Postgraduate training was the strongest predictor of higher adherence. Interviewed physiotherapists reported being highly satisfied with the care provided to patients with LBP even when psychosocial issues are present, despite low confidence in addressing those issues. Conclusions: Although overall adherence was high, Canadian physiotherapists do not frequently address psychosocial issues with LBP patients, and often do not feel confident or competent in that aspect of practice. This suggests an opportunity for developing additional training for addressing psychosocial issues in LBP patients.

Lower Back Pain as an Occupational Hazard Among Ugandan Health Workers

Background: Lower back pain is a public health concern affecting 70–85% of the world's population. There is paucity of published data on the prevalence, disability and risk factors for lower back pain among health workers in Uganda.

Objective: To determine the frequency rate (note that is it implicit that frequency is a rate like incidence so including rate seems redundant here. This is bounded by zero and infinity. In contrast, prevalence is bounded by 0 and 1 and is thus a proportion not a rate) of lower back pain and its associated risks amongst health professionals in the Arua District of Uganda.

Methods: Cross-sectional descriptive study of 245 consecutive participants conducted during February-April 2020. We stratified risks as individual or work related and analyzed the data using IBM SPSS version 25. Chi-square was used to measure the significance of association between categorical variables at 95% confidence interval, regarding a p ≤ 0.05 as significant.

Results: The mean age of participants was 40.87 years ± 8.74 (SD), with female predominance (69.8%). Majority were either general nurses or midwives (64.9%) and more than half had practiced for over 6–10 years. The frequency rate of lower back pain was 39.6% (n = 97). Individual factors associated with LBP were; cigarette smoking (X² = 33.040; P ≤ 0.001), alcohol consumption (X² = 13.581; P ≤ 0.001), age (X² = 14.717; P = 0.002), and female gender (X² = 4.802; P = 0.028). The work related factors significantly associated with lower back pain were: being a nurse/midwife (X² = 9.829; P = 0.007), working in the outpatient department (X² = 49.752; P ≤ 0.001), bending (X² = 43.912; P ≤ 0.001), lifting (X² = 33.279; P < 0.001), over standing (X² = 40.096; P ≤ 0.001), being in awkward positions (X² = 15.607; P= < 0.001), and pushing patients (X² = 21.999; P ≤ 0.001).

Conclusion: The frequency rate of low back pain was high amongst health workers and its main associated individual and work related factors could have been prevented. Health workers should strike a balance between caring for their personal back-health and meeting clients' needs while manually handling patients. Ergonomic structuring, job organization, back health care courses and use of assistive equipment could reduce such occupational hazards in our low resourced settings.

Relative contributions of the nervous system, spinal tissue and psychosocial health to non-specific low back pain: Multivariate meta-analysis

BACKGROUND AND OBJECTIVES

Nervous system, psychosocial and spinal tissue biomarkers are associated with non-specific low back pain (nsLBP), though relative contributions are unclear.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus were searched up to 25 March 2020. Related reviews and reference lists were also screened. Observational studies examining structural and functional nervous system biomarkers (e.g. quantitative sensory tests, structural and functional brain measures), psychosocial factors (e.g. mental health, catastrophizing) and structural spinal imaging biomarkers (e.g. intervertebral disc degeneration, paraspinal muscle size) between nsLBP and pain-free controls were included. For multivariate meta-analysis, two of three domains were required in each study. Random-effects pairwise and multivariate meta-analyses were performed. GRADE approach assessed evidence certainty. Newcastle-Ottawa scale assessed risk of bias. Main outcomes were the effect size difference of domains between nsLBP and pain-free controls.

RESULTS

Of 4519 unique records identified, 33 studies (LBP = 1552, referents = 1322) were meta-analysed. Psychosocial state (Hedges' g [95%CI]: 0.90 [0.69-1.10], p < 0.001) in nsLBP showed larger effect sizes than nervous system (0.31 [0.13-0.49], p < 0.001; difference: 0.61 [0.36-0.86], p < 0.001) and spine imaging biomarkers (0.55 [0.37-0.73], p < 0.001; difference: 0.36 [0.04-0.67], p = 0.027). The relationship between domains changes depending on if pain duration is acute or chronic.

CONCLUSIONS

Psychosocial effect sizes in nsLBP are greater than that for spinal imaging and nervous system biomarkers. Limitations include cross-sectional design of studies included and inference of causality. Future research should investigate the clinical relevance of these effect size differences in relation to pain intensity and disability.

STUDY REGISTRATION

PROSPERO-CRD42020159188.

SIGNIFICANCE

Spinal imaging (e.g. intervertebral disc degeneration), psychosocial (e.g. depression) and nervous system (e.g. quantitative sensory tests, structural and functional brain measures) biomarkers contribute to non-specific low back pain. However, psychosocial factors may be more compromised than nervous system and spinal imaging biomarkers. This relationship depends on if the pain is acute or chronic. These findings underscore that the 'non-specific' label in back pain should be reconsidered, and more specific multidimensional categories evaluated to guide patient management.

ICF-Based Assessment of Functioning in Daily Clinical Practice. A Promising Direction Toward Patient-Centred Care in Patients With Low Back Pain

Background: Patient-centred care has received increased attention in recent years. Patient-Reported Outcomes (PROs) and shared decision-making are key components of Patient-Centred care. Low back pain (LBP) is a complex symptom affected by multiple, interacting factors. Therefore, evidence strongly recommend a biopsychosocial and patient-centred approach in the assessment and management. The International Classification of Functioning, Disability and Health (ICF) provide a biopsychosocial model for describing functioning and disability. ICF is widely acknowledged, but implementation into clinical practice is lacking. To support the use of a biopsychosocial and patient-centred approach in daily clinical practice among patients with LBP we developed a practice-friendly tool based on ICF; the LBP assessment tool.

Objective: To compare an ICF-based assessment facilitated by the LBP assessment tool with standard care in terms of the use of PROs and shared decision-making in order to promote patient-centred care in patients with LBP.

Methods: A non-randomized controlled design was used. Eligible patients were allocated to one of two groups: the ICF group, assessed with the LBP assessment tool or the control group, assessed with a conventional LBP assessment. Primary outcome includes use of PROs. Secondary outcomes include use of a graphical overview displaying the patient profile and shared decision-making. A patient evaluation questionnaire was used to collect data.

Results: Seven hundred ten patients were assessed for eligibility of whom 531 were allocated to the ICF group (n = 299) or the control group (n = 232). A significantly higher use of PRO data (p < 0.00) and the patient profile (p < 0.00) was reported in favor of the ICF group. Patients in the ICF group also experienced being more involved in decision-making (p = 0.01).

Conclusions: This study showed that a functioning assessment, by means of the LBP assessment tool, increased use of PROs and shared decision-making when compared to a conventional LBP assessment. Additionally, this study demonstrated that routine use of ICF-based PRO data and shared decision-making promoted patient-centred care in patients with LBP. The LBP assessment tool may be a strong candidate for a user-friendly ICF-based tool with the potential to support health professionals in a shift toward a biopsychosocial and patient-centred approach to patients with LBP.

An interactive e-learning module to promote bio-psycho-social management of low back pain in healthcare professionals: a pilot study

Introduction: Low back pain (LBP) is ranked as the first musculoskeletal disorder considering years lived with disability worldwide. Despite numerous guidelines promoting a bio-psycho-social (BPS) approach in the management of patients with LBP, many health care professionals (HCPs) still manage LBP patients mainly from a biomedical point of view. Objective: The purpose of this pilot study was to evaluate the feasibility of implementing an interactive e-learning module on the management of LBP in HCPs. Methods: In total 22 HCPs evaluated the feasibility of the e-learning module with a questionnaire and open questions. Participants filled in the Back Pain Attitude Questionnaire (Back-PAQ) before and after completing the module to evaluate their attitudes and beliefs about LBP. Results: The module was structured and easy to complete (91%) and met the expectations of the participants (86%). A majority agreed that the module improved their knowledge (69%). Some participants (77%) identified specific topics that might be discussed in more detail in the module. HCPs knowledge, beliefs and attitudes about LBP significantly improved following module completion (t = -7.63, P < .001) with a very large effect size (d_s = -1.63). Conclusion: The module seems promising to change knowledge, attitudes and beliefs of the participants. There is an urgent need to develop and investigate the effect of educational interventions to favor best practice in LBP management and this type of e-learning support could promote the transition from a biomedical to a bio-psycho-social management of LBP in HCPs.

Lumbar movement control in non-specific chronic low back pain: Evaluation of a direction-specific battery of tests using item response theory

QUESTION

What tests are most useful to identify poor lumbar movement control (LMC) and what are the dimensional and psychometric properties of these tests?

DESIGN

Multicenter, cross-sectional cohort study.

PARTICIPANTS

Adults with non-specific chronic low back pain (NSCLBP).

METHODS

A literature review was conducted to identify LMC tests with good reliability (κ≥ 0.61) and their dimensionality was examined. Based on item response theory, psychometric properties of individual items and the entire battery of LMC tests were determined.

RESULTS

277 participants with NSCLBP were included and tested by 21 physiotherapists in 19 clinics in Germany and Austria. 15 tests for LMC were assessed. The battery of LMC tests showed a direction-specific structure representing extension, flexion and rotation/lateral flexion control, for which unidimensionality and local independence were confirmed (eigenvalue >1; factor loading >0.4, Yen's Q3 <0.2). 4 items for flexion control, 4 items for extension control and 5 items for rotation/lateral flexion control were extracted. The flexion control items were the easiest items (item difficulty: 1.98 to -1.31). The rotation/lateral flexion control items were the most difficult (-1.3 to -0.08). More than 80% of all participants showed at least one incorrect direction of LMC.

CONCLUSIONS

A battery of LMC tests is proposed as the most appropriate to examine individuals with precise to poor LMC. Each direction of LMC should be examined separately. Tests can be sorted according to test difficulty, so that only three tests are initially required to screen for poor LMC.

The advice given by physiotherapists to people with back pain in primary care

BACKGROUND

Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by clinicians to patients with back pain at their initial consultation.

METHODS

A secondary analysis was conducted with 25 audio-recordings and transcriptions of consultations between patients with back pain and physiotherapists in a primary care outpatients department. Using a Framework approach, the data were coded and analysed to identify the content of advice given and mode of delivery.

RESULTS

The mean duration of consultation was 38 min 59 s (range 26:21-53:16). Advice was given in 88% (n = 22/25) of consultations and 96% included additional exercise instruction. Cognitive reassurance was evident, focussing on getting people confident to 'move your back' despite pain and encouraging active lifestyle changes. Beyond reassurance and discussion to enhance confidence, the key topics of advice given were: activity promotion; postural changes; practical self-help advice regarding ways to sit; pain-management advice including medication and using heat. Gaps were identified in the advice given, most notably there was a lack of specificity relating to the frequency and duration of recommended tasks and activities.

CONCLUSIONS

Advice and reassurance are integral to enabling people to self-manage their back pain. It is important to avoid contradictory and unhelpful messages. Despite its importance, little is known about the advice offered by clinicians during initial back pain consultations highlighting the need for guidance to be patient-centred and tailored.

The relationship between readiness to change pain-related exercise participation and perceived work ability: a cross-sectional study of factory workers

BACKGROUND

Healthy lifestyle behaviours are associated with protection against health disorders and pain. Exercise participation is one such behaviour, associated with improved outcomes in those experiencing pain. Musculoskeletal pain is highly prevalent in the workplace, particularly in factory workers and associated loss of work function is recognised as having a great impact on individuals, society and the economy. A worker's 'readiness to change pain behaviour' is an important factor to consider in achieving a healthy lifestyle behaviour and potentially improved function. This study aimed to examine the relationship between a cohort of factory workers 'readiness to change pain behaviour' such as exercise and their 'perceived work ability'.

METHODS

A cross-sectional study design was used to establish the relationship between 'readiness to change pain behaviours' and 'perceived work ability'. The Multidimensional Pain Related Change Questionnaire 2 (MPRCQ2) was used to measure readiness to change various pain behaviours including exercise. The Work Ability Index (WAI) was used to assess 'perceived work ability'. Seventy-five factory workers, aged over 18 (66 male, 9 female) were recruited using convenience sampling between September-November 2019. Correlation and multiple regression were used for statistical analysis.

RESULTS

Mean WAI, MPRCQ2 and MPRCQ2 exercise component were 41.89 (SD 5.28), 4.26 (SD 1.01) and 4.40 (SD 1.69). MPRCQ2 and MPRCQ2 exercise component were not significant predictors of WAI in factory workers (F (2, 72) = 2.17, p > 0.001). There was no significant relationship between MPRCQ2 and WAI (rs = .09, p > .05). However, there was a significant positive relationship between MPRCQ2 exercise component and WAI (rs = .23, p < .05).

CONCLUSIONS

This study suggests that readiness to change pain-related exercise participation has a positive association with 'perceived work ability'. Further research should explore the causal relationship and consider strength training as a specific type of exercise.

Therapeutic Alliance: Patients' Expectations Before and Experiences After Physical Therapy for Low Back Pain-A Qualitative Study With 6-Month Follow-Up

OBJECTIVE

The aim of this study was to explore patients' expectations before and experiences after physical therapy for low back pain.

METHODS

Qualitative in-depth, semi-structured interviews with patients attending physical therapy were performed before, immediately after, and 6 months after treatment. Data were analyzed from a hermeneutical perspective with decontextualization, recontextualization, and identification of themes.

RESULTS

Patients' pretreatment expectations to physical therapy focused around exercises and a body-oriented diagnosis. After treatment, reassurance, active listening with explanations, and personally adapted strategies for self-managing pain and regaining control over everyday activity were expressed as decisive for a meaningful therapeutic alliance.

CONCLUSION

Expectations before treatment focused on exercises and diagnosis. Empathetic and personally adapted education aimed at empowerment was experienced as a meaningful aspect of the therapeutic alliance after treatment. The therapeutic alliance provided a basis to integrate knowledge on the complexity of pain.

IMPACT

Our findings indicate that patients emphasize physical therapists' interactional and pedagogical skills as meaningful aspects of the therapeutic alliance, which has implications for clinical practice and training physical therapist students.

Talking about chronic pain: Misalignment in discussions of the body, mind and social aspects in pain clinic consultations

In Western societies, human existence and illness are mostly constructed from the perspective of mind-body dualism: body and mind are considered to function independently, and the body/the physical as primary and more real. Research shows, however, that mind-body dualism is no longer tenable, especially in healthcare contexts. This led to the rise the biopsychosocial model, in which bodily experiences, including illness, are seen an interplay of the physical and the psychological, and the social. This model is the current gold standard for treating chronic pain. As these perspectives on the body and illness are potentially conflicting, and discursively constructed, this paper examines whether they are a source of misalignment in interactions between chronic pain patients and their doctors in a pain clinic. The analysis shows these perspectives indeed lead to misalignment, for instance when discussing the relevance of psychotherapy, and lead to intricate uses of argumentative resources to account for the differing perspectives on (the treatment of) pain.