A modified Delphi approach to standardize low back pain recurrence terminology

Passion and performance anxiety: How it affects the incidence of musculoskeletal disorders in dancers

OBJECTIVES

This study aimed to examine the association between the incidence of musculoskeletal disorder episodes (MDEs) and obsessive and harmonious passion as well as performance anxiety throughout a dance season, which lasted 38 weeks.

DESIGN

Prospective cohort study.

METHODS

A total of 118 professional and preprofessional dancers were recruited and assessed at baseline, while 88 completed the follow-up. Their levels of passion and performance anxiety were assessed at the beginning of a dance season using the Passion Scale and the Kenny Music Performance Anxiety Inventory, respectively. To monitor the incidence of MDEs throughout a dance season, dancers were asked to complete a weekly electronic diary.

RESULTS

A higher level of obsessive passion was associated with a higher incidence of MDEs causing an interruption of dance activities (β = 0.264, p = 0.022). Harmonious passion and performance anxiety were not associated with MDEs throughout the season.

CONCLUSIONS

Findings of this study support the role of obsessive passion in the development of MDEs in dancers.

MyBack - effectiveness and implementation of a behavior change informed exercise programme to prevent low back pain recurrences: a hybrid effectiveness-implementation randomized controlled study protocol

BACKGROUND

Low back pain (LBP) is a common health condition and the leading cause of years lived with disability worldwide. Most LBP episodes have a favourable prognosis, but recurrences within a year are common. Despite the individual and societal impact related to LBP recurrences, there is limited evidence on effective strategies for secondary prevention of LBP and successful implementation of intervention programmes in a real-world context. The aim of this study is to analyse the effectiveness of a tailored exercise and behavioural change programme (MyBack programme) in the secondary prevention of LBP; and evaluate acceptability, feasibility and determinants of implementation by the different stakeholders, as well as the implementation strategy of the MyBack programme in real context.

METHODS

This protocol describes a hybrid type I, randomized controlled trial to evaluate the effectiveness and implementation of MyBack programme in the context of primary health care. The Behaviour Change Wheel framework and FITT-VP principles will inform the development of the behaviour change and exercise component of MyBack programme, respectively. Patients who have recently recovered from an episode of non-specific LBP will be randomly assigned to MyBack and usual care group or usual care group. The primary outcome will be the risk of LBP recurrence. The secondary outcomes will include disability, pain intensity, musculoskeletal health, and health-related quality of life. Participants will be followed monthly for 1 year. Costs data related to health care use and the MyBack programme will be also collected. Implementation outcomes will be assessed in parallel with the effectiveness study using qualitative methods (focus groups with participants and health providers) and quantitative data (study enrolment and participation data; participants adherence).

DISCUSSION

To our knowledge, this is the first study assessing the effectiveness and implementation of a tailored exercise and behaviour change programme for prevention of LBP recurrences. Despite challenges related to hybrid design, it is expected that data on the effectiveness, cost-effectiveness, and implementation of the MyBack programme may contribute to improve health care in patients at risk of LBP recurrences, contributing to direct and indirect costs reduction for patients and the health system.

TRIAL REGISTRATION NUMBER

NCT05841732.

Machine learning-based identification of determinants for rehabilitation success and future healthcare use prevention in patients with high-grade, chronic, nonspecific low back pain: an individual data 7-year follow-up analysis on 154,167 individuals

ABSTRACT

To individually prescribe rehabilitation contents, it is of importance to know and quantify factors for rehabilitation success and the risk for a future healthcare use. The objective of our multivariable prediction model was to determine factors of rehabilitation success and the risk for a future healthcare use in patients with high-grade, chronic low back pain. We included members of the German pension fund who participated from 2012 to 2019 in multimodal medical rehabilitation with physical and psychological treatment strategies because of low back pain (ICD10:M54.5). Candidate prognostic factors for rehabilitation success and for a future healthcare use were identified using Gradient Boosting Machines and Random Forest algorithms in the R-package caret on a 70% training and a 30% test set. We analysed data from 154,167 patients; 8015 with a second medical rehabilitation measure and 5161 who retired because of low back pain within the study period. The root-mean-square errors ranged between 494 (recurrent rehabilitation) and 523 (retirement) days ( R2 = 0.183-0.229), whereas the prediction accuracy ranged between 81.9% for the prediction of the rehabilitation outcome, and 94.8% for the future healthcare use prediction model. Many modifiable prognostic factors (such as duration of the rehabilitation [inverted u-shaped], type of the rehabilitation, and aftercare measure), nonmodifiable prognostic factors (such as sex and age), and disease-specific factors (such as sick leave days before the rehabilitation [linear positive] together with the pain grades) for rehabilitation success were identified. Inpatient medical rehabilitation programmes (3 weeks) may be more effective in preventing a second rehabilitation measure and/or early retirement because of low back pain compared with outpatient rehabilitation programs. Subsequent implementation of additional exercise programmes, cognitive behavioural aftercare treatment, and following scheduled aftercare are likely to be beneficial.

Conditioned pain modulation, kinesiophobia, and pain catastrophizing as prognostic factors for chronicity in a population with acute low back pain: An exploratory prospective study

BACKGROUND

Psychosocial factors and alteration of the somatosensory functions have been associated with persistent low back pain (LBP). A decreased capacity of the central nervous system to modulate pain has been suggested as a potential contributor to the persistence of pain.

OBJECTIVE

To investigate whether conditioned pain modulation (CPM), initial symptoms/disability, kinesiophobia, and pain catastrophizing is associated with the transition from acute to chronic LBP.

DESIGN

Prospective cohort study.

METHOD

Fifty participants presenting with acute LBP (<6 weeks) took part in three evaluation sessions (baseline, 3 and 6 months). At baseline and 3-month evaluations, all participants completed self-administered questionnaires (Oswestry Disability Index [ODI], Short Form of Brief Pain Inventory [BPI-SF], Tampa Scale of Kinesiophobia [TSK] and Pain Catastrophizing Scale [PCS]) and CPM was assessed. At the 6-month evaluation, questionnaires were readministered, and participants were dichotomized according to their status (Non-chronic LBP [NCLBP] or chronic LBP [CLBP]). Univariate tests were used to compare baseline variables between NCLBP and CLBP.

RESULTS

No significant baseline difference was found for TSK (p = 0.48), PCS (p = 0.78), CPM (p = 0.82), ODI (p = 0.78), BPI-SF severity (p = 0.50), and interference subscales (p = 0.54) between those categorized as NCLBP or CLBP at 6 months.

CONCLUSIONS

This exploratory study failed to support the hypothesis that inefficient CPM mechanisms and the presence of psychological factors could be factors associated with the transition to chronic pain in individuals with acute LBP.

Transition from Acute to Chronic Low Back Pain in a Community-Based Cohort

The transition from acute to chronic low back pain (LBP) in community settings has yet to be well understood. We recruited n=131 participants with acute LBP from the community and followed them for 3 and 6-month outcomes. Acute LBP was defined by a duration of < 4 weeks, and participants must have reported a 30-day LBP-free period before the current acute episode. Chronic LBP was defined as pain most or every day over the past 3 months. Baseline psychological, social, and demographic factors were examined as predictors of transition to chronic LBP at 3 months or continuation of chronic LBP at 6 months. The transition from acute to chronic LBP at 3 months was 32.2% ( 38/118). At 6 months, 80.7% (25/111) of participants who transitioned at 3 months continued to have chronic LBP. At 6 months, participants who identified as Black or African American were more likely than white participants to transition to chronic LBP (RR=1.76, 95% CI 1.05, 2.95) and more likely to continue to have chronic LBP (RR=2.19, 95% CI 1.14, 4.21). Those classified at baseline by both LBP most or every day and intensity of at least 30/100 were more likely to transition to chronic LBP (RR=3.13, 95% CI 1.84, 5.30) and continue to have chronic LBP at 6 months (RR=2.58, 95% CI 1.43, 4.16). The STarT Back Screening Tool and the OSPRO-YF were associated with the transition to chronic LBP at 3 months and continuation at 6 months. Participants with higher PROMIS General Health and PROMIS Physical Health scores were less likely to transition to chronic LBP or continue to have chronic LBP at 6 months. These findings identify factors of acute LBP in the community that may predict the transition to chronic LBP. Larger studies are needed to confirm these findings and better understand the mechanisms driving the transition to chronic LBP.

Characterizing Acute Low Back Pain in a Community-Based Cohort

Acute low back pain (LBP) is a common experience, however, the associated pain severity, pain frequency, and characteristics of individuals with acute LBP in community settings have yet to be well understood. The purpose of this manuscript is to categorize and compare acute LBP groups for differences in the following characteristics: 1) sociodemographic, 2) general and physical health, and 3) psychological. This cross-sectional study used baseline data from 131 community-based participants with acute LBP (<4 weeks duration before screening and > 30 pain-free days before acute LBP onset). Two LBP categorization definitions were used based on LBP frequency combined with either: 1) pain interference frequency (impact-based) or 2) pain intensity (intensity-based). Descriptive associations were calculated as prevalence ratios for categorical variables and Hedges' g for continuous variables. Our analyses identified several large associations for impact-based and intensity-based categories for pain interference with activity and with enjoyment in life, global mental health, STarT Back Screening Tool risk category, general health, and Fear Avoidance Beliefs Questionnaire-Physical Activity subscale. Larger associations were found with social constructs (racially and ethnically minoritized, performance of social roles, and isolation) when using the intensity-based versus impact-based categorization. This study adds to the literature by providing standard ways to characterize community-based individuals experiencing acute LBP. The robust differences observed between these categorization approaches suggest they may be used to improve the early identification of factors potentially contributing to the development of chronic LBP.

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

The effects of dynamic neuromuscular stabilization approach on clinical outcomes in older patients with chronic nonspecific low back pain: a randomized, controlled clinical trial

OBJECTIVE

We aimed to examine the effects of Dynamic Neuromuscular Stabilization (DNS) approach in older patients with chronic non-specific low back pain (CNSLBP).

METHODS

A total of 72 participants with CNSLBP were assigned to either the experimental group (n = 36) or control group (n = 36) in this randomized study. A conventional physiotherapy program was administered to the participants in the control group for 3 days per week for a total of 6 weeks. In addition to the conventional program, DNS exercise protocol was performed for 3 days per week for 6 weeks for the participants in the experimental group. While quality of movements and exercise capacity were our primary outcomes, functional balance and quality of life constituted our secondary outcomes. The participants were assessed both at baseline and post-treatment.

RESULTS

The improvement in a deep squat, in-line lunge, hurdle step, shoulder flexibility, rotary trunk stability, total Functional Movement Screening score, and Timed-up and Go Test score was greater in the experimental group (p<.05). The improvement was similar in both groups in terms of the rest of outcome measures.

DISCUSSION

This study demonstrated the effectiveness of the DNS approach on some functional movement patterns and functional balance performance in older patients with CNSLBP.

Do Visual Pain Trajectories Reflect the Actual Course of Low Back Pain? A Longitudinal Cohort Study

Different trajectories of low back pain (LBP) have been identified prospectively using repeated measures. For these trajectories to inform clinical practice, they must be available in the clinical consultation. Therefore, identified LBP trajectories have been translated into visual pain trajectories (VPTs) that allow people with LBP, at the time of consult, to reflect upon their pain experience and identify the VPT that best categorizes their pain course. We have limited knowledge regarding the extent to which a chosen VPT reflects the prospectively experienced trajectory. Thus, we explored the distribution of pain intensity and pain pattern characteristics (from prospective pain trajectory data) within the retrospectively chosen VPT classes. We enrolled patients with LBP from Danish chiropractic practice. Using SMS, participants (n = 719) scored their pain weekly on an 11-point numerical rating scale for 52 weeks. At week 52, participants identified 1 of 8 VPTs that reflected their perceived back pain trajectory during the preceding year. We found that the chosen VPTs reflected pain intensity, but that pain patterns (episodic, fluctuating, and persistent) were not systematically recognized, and the experienced course varied substantially amongst participants within the same VPT. The VPTs are related to some aspects of the experienced LBP course but are not a proxy for the SMS-measured trajectories. Reasons for apparent mismatches between the experienced course of LBP and VPT recall warrant further investigation. PERSPECTIVE: Self-reported back pain trajectories reflected pain intensities obtained through weekly SMS tracking over a year, but participants' recall did not reflect the pain patterns (episodes and fluctuations) discovered prospectively. Clinicians can use self-reported pain trajectories to facilitate a dialog about pain experience, but not as a proxy for prospective measures.

Associations between psychological factors, pressure pain thresholds and conditioned pain modulation and disability in (sub)-acute low back pain: a three-month follow-up study

BACKGROUND

The clinical presentation and pain experience of patients with (sub)-acute low back pain ((S)ALBP) can strongly vary in clinical practice. However, despite growing evidence that psychological factors are associated with disability in chronic pain conditions including low back pain, studies examining the influence of psychological factors, quantitative sensory testing (QST) (i.e. pressure pain thresholds (PPTs)) and conditioned pain modulation (CPM) on future disability are still lacking in (S)ALBP.

OBJECTIVE

This prospective cohort study aims to determine associations between baseline psychological factors, PPTs and CPM in (S)ALBP and disability after 3 months.

METHODS

Fifty-two patients with (S)ALBP underwent a baseline PPT evaluation in rest and during a CPM protocol. Patients were asked to fill in self-report questionnaires: the Visual Analogue Scale (VAS), the Quebec Back Pain Disability Scale (QBPDS), the Pain Catastrophizing Scale (PCS), the Tampa Scale for Kinesiophobia (TSK) and the Illness Perception Questionnaire - Brief version (IPQ-B). At 3-month follow-up, participants were asked to fill in the QBPDS again. Multiple linear regression analysis was conducted to determine associations between baseline factors and disability at follow-up.

RESULTS

Thirty-eight patients participated at follow-up. Because of the multicollinearity issue, the TSK score was selected for analyses and the PCS and IPQ-B score were excluded from the model. No significant associations between baseline factors and disability at follow-up were found.

CONCLUSION

Neither baseline psychological factors nor PPTs or CPM in (S)ALBP were significantly associated with disability after 3 months. Our multiple linear regression analysis was likely underpowered to detect significant associations.

Establishing a Standardized Clinical Consensus for Reporting Complications Following Lateral Lumbar Interbody Fusion

Background and Objectives: Mitigating post-operative complications is a key metric of success following interbody fusion. LLIF is associated with a unique complication profile when compared to other approaches, and while numerous studies have attempted to report the incidence of post-operative complications, there is currently no consensus regarding their definitions or reporting structure. The aim of this study was to standardize the classification of complications specific to lateral lumbar interbody fusion (LLIF). Materials and Methods: A search algorithm was employed to identify all the articles that described complications following LLIF. A modified Delphi technique was then used to perform three rounds of consensus among twenty-six anonymized experts across seven countries. Published complications were classified as major, minor, or non-complications using a 60% agreement threshold for consensus. Results: A total of 23 articles were extracted, describing 52 individual complications associated with LLIF. In Round 1, forty-one of the fifty-two events were identified as a complication, while seven were considered to be approach-related occurrences. In Round 2, 36 of the 41 events with complication consensus were classified as major or minor. In Round 3, forty-nine of the fifty-two events were ultimately classified into major or minor complications with consensus, while three events remained without agreement. Vascular injuries, long-term neurologic deficits, and return to the operating room for various etiologies were identified as important consensus complications following LLIF. Non-union did not reach significance and was not classified as a complication. Conclusions: These data provide the first, systematic classification scheme of complications following LLIF. These findings may improve the consistency in the future reporting and analysis of surgical outcomes following LLIF.

Effectiveness and cost-effectiveness of a progressive, individualised walking and education program for prevention of low back pain recurrence in adults: statistical analysis plan for the WalkBack randomised controlled trial

BACKGROUND

Exercise for the prevention of low back pain recurrences is recommended, but under-researched. The effectiveness and cost-effectiveness of a walking program for preventing low back pain recurrence remains unknown. This a priori statistical analysis plan describes the methods of analysis for the WalkBack trial.

METHODS

WalkBack is a prospectively registered, pragmatic, randomised controlled trial. The aim is to investigate the effectiveness and cost-effectiveness of a 6-month progressive and individualised walking and education program (intervention) for the prevention of low back pain recurrences, compared to a no-treatment control group. The primary outcome is days to the first recurrence of an episode of activity-limiting low back pain. Key secondary outcomes include days to any recurrence of low back pain, days to a care-seeking recurrence of low back pain, disability level, health-related quality of life, costs associated with low back pain and adverse events. All participants will be followed for a minimum of 12 months. Analysis will follow the intention-to-treat principle. Cox regression is planned to assess the effects for the outcomes of time to activity-limiting, minimal and care-seeking recurrence. Hazard ratios and median survival times with 95% confidence intervals will be calculated. The effect of the intervention on continuous outcomes will be estimated with repeated-measure linear mixed models. An economic evaluation will be performed from the societal perspective for recurrence prevented (yes/no) and quality-adjusted life years. The proportion of adverse events between groups will be compared using Fisher's exact test.

DISCUSSION

The WalkBack trial will provide evidence on the effectiveness and cost-effectiveness of a walking intervention to prevent low back pain recurrences. This statistical analysis plan provides transparency on the analysis of the trial.

TRIAL REGISTRATION

WalkBack - Effectiveness and cost-effectiveness of a progressive individualised walking and education program for the prevention of a recurrence of low back pain. ACTRN12619001134112 . Date Registered: 14/08/2019.

Recurrence of low back pain: A difficult outcome to predict. Development and validation of a multivariable prediction model for recurrence in patients recently recovered from an episode of non-specific low back pain

BACKGROUND

Recurrence of low back pain (LBP) is common. If clinicians could identify an individual's risk of recurrence, this would enhance clinical decision-making and tailored patient care.

OBJECTIVE/DESIGN

To develop and validate a simple tool to predict the probability of a recurrence of LBP by 3- or 12-months following recovery.

METHODS

Data utilised for the prediction model development came from a prospective inception cohort study of participants (n = 250) recently recovered from LBP, who had sought care from chiropractic or physiotherapy services. The outcome measure was a recurrence of activity-limiting LBP. Candidate predictor variables (e.g., basic demographics, LBP history, levels of physical activity, etc) collected at baseline were considered for inclusion in a multivariable Cox model. The model's performance was tested in a separate validation dataset of participants (n = 261) involved in a randomised controlled trial investigating exercise for the prevention of LBP recurrences.

RESULTS

The final model included the number of previous episodes, total sitting time, and level of education. In the development sample, discrimination was acceptable (Harrell's C-statistic = 0.61, 95% CI, 0.59-0.62), but in the validation sample, discrimination was poor (0.56, 95% CI, 0.54-0.58). Calibration of the model in the validation dataset was acceptable at 3 months but was less precise at 12 months.

CONCLUSION

The developed prediction model, which included number of previous episodes, total sitting time, and level of education, did not perform adequately in the validation sample to recommend its use in clinical practice. Predicting recurrence of LBP in clinical practice remains challenging.

The relationship between the Keele STarT back screening tool, the short form of central sensitivity inventory and health-related quality of life in patients with low back pain

INTRODUCTION

It has been reported that the scores of the Keele STarT Back Screening Tool (SBST) and the short form of Central Sensitization Inventory (CSI-9) are associated with Health-Related Quality of Life (HRQoL) in patients with low back pain (LBP). However, it is unclear which screening tool is more associated with HRQoL in patients with LBP.

OBJECTIVE

To identify which SBST and CSI-9 are more related to HRQoL and investigate the association between SBST and CSI-9 scores.

STUDY DESIGN

Cross-sectional study.

METHOD

A multiple regression analysis was conducted to examine the factors associated with the HRQoL using age, pain intensity, disability, SBST score, and CSI-9 score as independent variables. Spearman's rank correlation coefficient was also conducted to determine the association between SBST and CSI-9 score.

RESULTS

Multiple regression analysis revealed that the Oswestry Disability Index (ODI) score (p < 0.01, β = -0.62, VIF = 1.70) and SBST score (p < 0.01, β = -0.32, VIF = 1.86) were significant associated variables. A significant association was found between SBST and CSI-9 scores (p < 0.01, ρ = 0.47).

CONCLUSION

The results showed that in patients with LBP the association of HRQoL with SBST was more substantial than with CSI-9.

Treatment preference changes after exposure to treatment in adults with chronic low back pain

BACKGROUND

Patients' pretreatment preferences can influence outcomes of nonpharmacologic treatments for musculoskeletal pain. Less is known about how patients' treatment preferences change following exposure to treatment.

OBJECTIVE

To examine the effect of exposure to treatment and change in disability and pain on treatment preference ratings of two exercise-based treatments for people with chronic low back pain (LBP).

DESIGN

Secondary analysis of a subsample of participants from a randomized clinical trial.

SETTING

Academic research setting.

PARTICIPANTS

Individuals with chronic LBP (n = 83).

INTERVENTIONS

6 weekly sessions of motor skill training (MST) or strength and flexibility exercise (SFE).

MAIN OUTCOME MEASURES

Prior to treatment, participants completed a treatment preference assessment measure (TPA) describing MST and SFE. Participants rated four attributes (effectiveness, acceptability/logicality, suitability/appropriateness, convenience) of each treatment on a 5-point Likert scale (0-4) with higher scores indicating higher ratings. An overall preference rating was calculated as the mean of the attribute ratings. The TPA was administered 12 months post treatment to reassess participants' ratings of the treatment they received.

RESULTS

Participants who received MST rated their preference for MST higher 12 months post treatment and participants who received SFE rated their preference for SFE lower. Smaller improvements (to worsening) in pain were associated with a reduction in preference ratings in the SFE group, whereas the MST group generally increased their ratings regardless of pain. Changes in disability were not related to changes in preference ratings.

CONCLUSIONS

Participants changed their preference ratings of two exercise-based treatments for LBP after exposure to the treatment. Participants who received the less familiar MST viewed this treatment more favorably 12 months post treatment, and this change was less contingent on changes in disability/pain than for participants in the SFE group. Assessing preference ratings at various times during treatment is crucial to understand a person's preference for and perceptions of a treatment.

Exploring visual pain trajectories in neck pain patients, using clinical course, SMS-based patterns, and patient characteristics: a cohort study

Background

The dynamic nature of neck pain has so far been identified through longitudinal studies with frequent measures, a method which is time-consuming and impractical. Pictures illustrating different courses of pain may be an alternative solution, usable in both clinical work and research, but it is unknown how well they capture the clinical course. The aim of this study was to explore and describe self-reported visual trajectories in terms of details of patients’ prospectively reported clinical course, their SMS-based pattern classification of neck pain, and patient’s characteristics.

Methods

Prospective cohort study including 888 neck pain patients from chiropractic practice, responding to weekly SMS-questions about pain intensity for 1 year from 2015 to 2017. Patients were classified into one of three clinical course patterns using definitions based on previously published descriptors. At 1-year follow-up, patients selected a visual trajectory that best represented their retrospective 1-year course of pain: single episode, episodic, mild ongoing, fluctuating and severe ongoing.

Results

The visual trajectories generally resembled the 1-year clinical course characteristics on group level, but there were large individual variations. Patients selecting Episodic and Mild ongoing visual trajectories were similar on most parameters. The visual trajectories generally resembled more the clinical course of the last quarter.

Discussion

The visual trajectories reflected the descriptors of the clinical course of pain captured by weekly SMS measures on a group level and formed groups of patients that differed on symptoms and characteristics. However, there were large variations in symptoms and characteristics within, as well as overlap between, each visual trajectory. In particular, patients with mild pain seemed predisposed to recall bias. Although the visual trajectories and SMS-based classifications appear related, visual trajectories likely capture more elements of the pain experience than just the course of pain. Therefore, they cannot be seen as a proxy for SMS-tracking of pain over 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00443-3.

Development and internal validation of a machine learning prediction model for low back pain non-recovery in patients with an acute episode consulting a physiotherapist in primary care

Background

While low back pain occurs in nearly everybody and is the leading cause of disability worldwide, we lack instruments to accurately predict persistence of acute low back pain. We aimed to develop and internally validate a machine learning model predicting non-recovery in acute low back pain and to compare this with current practice and ‘traditional’ prediction modeling.

Methods

Prognostic cohort-study in primary care physiotherapy. Patients (n = 247) with acute low back pain (≤ one month) consulting physiotherapists were included. Candidate predictors were assessed by questionnaire at baseline and (to capture early recovery) after one and two weeks. Primary outcome was non-recovery after three months, defined as at least mild pain (Numeric Rating Scale > 2/10). Machine learning models to predict non-recovery were developed and internally validated, and compared with two current practices in physiotherapy (STarT Back tool and physiotherapists’ expectation) and ‘traditional’ logistic regression analysis.

Results

Forty-seven percent of the participants did not recover at three months. The best performing machine learning model showed acceptable predictive performance (area under the curve: 0.66). Although this was no better than a’traditional’ logistic regression model, it outperformed current practice.

Conclusions

We developed two prognostic models containing partially different predictors, with acceptable performance for predicting (non-)recovery in patients with acute LBP, which was better than current practice. Our prognostic models have the potential of integration in a clinical decision support system to facilitate data-driven, personalized treatment of acute low back pain, but needs external validation first.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05718-7.

A network analysis reveals the interaction between fear and physical features in people with neck pain

Although neck pain is known to be a complex and multifactorial condition characterised by the interplay between physical and psychological domains, a comprehensive investigation examining the interactions across multiple features is still lacking. In this study, we aimed to unravel the structure of associations between physical measures of neuromuscular function and fear of movement in people with a history of neck pain. One hundred participants (mean age 33.3 ± 9.4) were assessed for this cross-sectional study, and the neuromuscular and kinematic features investigated were the range of motion, velocity of neck movement, smoothness of neck movement, neck proprioception (measured as the joint reposition error), and neck flexion and extension strength. The Tampa Scale for Kinesiophobia was used to assess fear of movement. A network analysis was conducted to estimate the associations across features, as well as the role of each feature in the network. The estimated network revealed that fear of movement and neuromuscular/kinematic features were conditionally dependent. Higher fear of movement was associated with a lower range of motion, velocity, smoothness of neck movement, neck muscle strength, and proprioception (partial correlations between − 0.05 and − 0.12). Strong interactions were also found between kinematics features, with partial correlations of 0.39 and 0.58 between the range of motion and velocity, and between velocity and smoothness, respectively. The velocity of neck movement was the most important feature in the network since it showed the highest strength value. Using a novel approach to analysis, this study revealed that fear of movement can be associated with a spectrum of neuromuscular/kinematic adaptations in people with a history of neck pain.

Recurrence of an Episode of Low Back Pain: An Inception Cohort Study in Emergency Departments

OBJECTIVES

To (1) determine the 1-year estimate of recurrence of low back pain (LBP) in a cohort of people presenting to emergency departments who have recently recovered from an episode of acute LBP in a middle-income country, (2) estimate a recurrence of LBP stratified by the STarT Back Screening Tool (SBST), and (3) determine prognostic factors for the recurrence of LBP.

DESIGN

Prospective inception cohort study.

METHODS

We included 238 patients who presented to emergency departments with recent-onset nonspecific LBP in São Paulo, Brazil. The outcome was the recurrence of an episode of LBP, assessed using 2 definitions: (1) 12-month recall alone and (2) pain measurements at follow-up. Prognostic factors were determined by logistic regression.

RESULTS

Within 1 year, the estimated recurrence of an episode of LBP ranged from 35% (79/225 events) (first definition) to 44% (100/226 events) (second definition). When patients were stratified by the SBST, the estimate of recurrence ranged from 29% to 37% (21-27/73 events) for low-risk patients, from 33% to 39% (24-28/72 events) for medium-risk patients, and from 43% to 56% (34-45/80 events) for high-risk patients. Age, perceived risk of persistent LBP, and disability were independent prognostic factors associated with LBP recurrence within 1 year.

CONCLUSION

After recovering from a previous episode of acute LBP, 4 in every 10 patients experienced a recurrence within 1 year. This estimate varied depending on the classification used in the SBST. Within 1 year, age, perceived risk of persistent LBP, and baseline disability were predictors of recurrence. J Orthop Sports Phys Ther 2022;52(7):484-492. Epub: 18 May 2022. doi:10.2519/jospt.2022.10775.

Perceived Severity and Management of Low Back Pain in Adult Dancers in the United States

INTRODUCTION

Low back pain (LBP) lifetime prevalence in dancers reportedly ranges from 17% to 88%. Low back pain can have negative secondary consequences on dancers' lives and careers. Still, how LBP impacts dancer function and medical care-seeking behaviors and whether these issues differ across dance genres, is understudied.

MATERIALS AND METHODS

Two hundred and eight-nine ballet, modern, and hip-hop dancers and teachers (median age: 20.3 years; range: 18 to 69 years) in the United States completed an online 24-question survey assessing LBP related self-reported injury history, impact on their lives, and management strategies. We defined LBP as occurrence of acute or chronic pain in the lumbar or sacral regions of the back.

RESULTS

Two hundred and fifty-seven participants (88.9% of 289 total) reported at least one instance of LBP during their lifetime and 220 participants reported LBP in the prior 4 weeks. Of these 220, 72 (32.7%) had LBP severe enough to limit their activities of daily living. Of the 213 who had LBP and danced during that time, 89 (41.8%) reported that LBP limited their dancing. Pain intensity (median: 4 on a 0 to 10 scale, IQR: 3.0) and LBP prevalence were similar across dance genres. Dancers sought multiple medical professionals, most often chiropractors (n = 94, 33.8%), medical doctors (n = 77, 27.7%), and physiotherapists (n = 60, 21.6%). Ninety dancers (35.0% of those with LBP) never sought medical care. Dancers who did seek care reported higher pain intensities (median: 4, IQR: 3.8) than those who did not (median: 3, IQR: 3.0).

CONCLUSION

Overall, most participants did suffer from LBP. Low back pain negatively impacts dancers' everyday activities and dancing. Pain intensity and loss of function may impact care-seeking. Our findings highlight the need for all dance stakeholders to educate dancers about their health, provide resources for dancer health care, and proactively create an environment that supports injury reporting behaviors in dancers.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BACKGROUND

Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.

METHODS

Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.

DISCUSSION

FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

Associations between perceived quantitative work demands at different organisational levels and pain and sickness absence in eldercare workers: a multi-level longitudinal analysis

PURPOSE

Eldercare work is characterised by high quantitative work demands and high occurrence of musculoskeletal pain and sickness absence. Our aim was to investigate the association between quantitative demands aggregated at the different organizational levels of eldercare and low back pain (LBP) and sickness absence due to pain among workers.

METHODS

This study was conducted in 527 eldercare workers from 105 wards across 20 nursing homes in Denmark. We collected workers' perceived quantitative demands at baseline and workers' LBP and sickness absence repeatedly over the following year. We aggregated worker-level quantitative demands to the ward and nursing home-levels, and used mixed-effects regression models to investigate the associations between quantitative demands at different organizational levels and LBP and sickness absence over 1 year.

RESULTS

Across all models, increased quantitative demands (0-100 scale) at the worker-level was associated with an increased likelihood (OR 1.02) and intensity of LBP (β = 0.01). We did not identify any associations between quantitative demands at the ward-level and either of our outcomes. Across all models, increased quantitative demands at the nursing home-level was associated with increased days with sickness absence due to pain (β = 0.03 to 0.06).

CONCLUSION

In eldercare, workers' perceived quantitative demands are associated with the presence and intensity of LBP. Further, quantitative demands across the overall nursing home-level are associated with sickness absence due to pain among eldercare workers. These results are of relevance to developing organisational interventions targeting quantitative demands to reduce sickness absence in eldercare.

Assessment of Neuromuscular and Psychological Function in People with Recurrent Neck Pain during a Period of Remission: Cross-Sectional and Longitudinal Analyses

The aim of this study was to examine for the presence of differences in neuromuscular and psychological function in individuals with recurrent neck pain (RNP) or chronic neck pain (CNP) following a whiplash trauma compared to healthy controls. A secondary aim was to examine whether neuromuscular characteristics together with psychological features in people with RNP were predictive of future painful episodes. Multiple features were assessed including neck disability, kinesiophobia, quality of life, cervical kinematics, proprioception, activity of superficial neck flexor muscles, maximum neck flexion and extension strength, and perceived exertion during submaximal contractions. Overall, those with RNP (n = 22) and CNP (n = 8) presented with higher neck disability, greater kinesiophobia, lower quality of life, slower and irregular neck movements, and less neck strength compared to controls (n = 15). Prediction analysis in the RNP group revealed that a higher number of previous pain episodes within the last 12 months along with lower neck flexion strength were predictors of higher neck disability at a 6-month follow-up. This preliminary study shows that participants with RNP presented with some degree of altered neuromuscular features and poorer psychological function with respect to healthy controls and these features were similar to those with CNP. Neck flexor weakness was predictive of future neck disability.

Low back pain definitions: effect on patient inclusion and clinical profiles

Supplemental Digital Content is Available in the Text.

Differences in sample size and group characteristics were observed in a cohort study depending on the definition of acute low back pain applied.

Introduction:

Numerous definitions of acute low back pain (aLBP) exist. The use of different definitions results in variability in reported prevalence or incidence, conflicting data regarding factors associated with the transition to chronic LBP (cLBP), and hampers comparability among studies.

Objective:

Here, we compare the impact of 3 aLBP definitions on the number of aLBP cases and participants' characteristics and explore the distribution of participants across definitions.

Methods:

A sample of 1264 participants from the Quebec Low Back Pain Study was included. Three definitions of aLBP were used: (1) not meeting the National Institutes of Health (NIH) cLBP definition (“nonchronic”), (2) pain beginning <3 months ago (“acute”), and (3) pain beginning <3 months with a preceding LBP-free period (“new episode”).

Results:

There were 847, 842, and 489 aLBP cases meeting the criteria for the 3 definitions, respectively. Participants included in the “nonchronic” had lower pain interference, greater physical function scores, and fewer participants reporting >5 years of pain than in the other definitions. Half the participants meeting the “acute” definition and one-third of participants meeting the “new episode” definition were also classified as cLBP based on the NIH definition.

Conclusions:

Our results highlight the importance of the definition used for aLBP. Different definitions influence the sample size and clinical profiles (group's characteristics). We recommended that cohort studies examining the transition from aLBP to cLBP ensure that the definitions selected are mutually exclusive (ie, participants included [aLBP] differ from the expected outcome [cLBP]).

The Reliability and Validity of Gluteal Endurance Measures (GEMs)

BACKGROUND

The gluteals have unique morphology related to muscle endurance, including moderate fiber sizes and a majority of Type I endurance fibers. Evidence suggests gluteal endurance is related to low back pain, running kinematics, balance, posture, and more. However, reliable and valid measures specific to gluteal endurance are lacking in the literature.

HYPOTHESIS/PURPOSE

The purpose of this study was to examine the intra- and inter-rater reliability of two gluteal endurance measures (GEMs) for clinical use. It also aimed to examine validity for the two measures by using electromyography (EMG), recording reasons for task failure, and analyzing differences between demographic groups.

STUDY DESIGN

Cross-Sectional.

METHODS

Sixty-eight males and females with and without recurrent low back pain aged 18-35 years were recruited from a university population. Electromyography electrodes were placed on subjects' gluteus maximus and gluteus medius, and each subject performed three trials of GEM-A (abduction endurance) and GEM-B (bridging endurance). Hold times, EMG median frequency (MF) data, and subjective reasons for task failure were analyzed.

RESULTS

Both GEMs demonstrated high intra-rater reliability (ICC = 0.87-0.94) and inter-rater reliability (ICC = 0.99). Mean hold times were 104.83 ± 34.11 seconds for GEM-A (abduction endurance) and 81.03 ± 24.79 seconds for GEM-B (bridging endurance). No statistically significant difference was found between subjects with and without recurrent LBP. Median frequency data validated the onset of gluteal fatigue during both measures. Posterolateral hip (gluteal) fatigue was reported as the primary reason for task failure in 93% and 86% of subjects for GEM-A and GEM-B, respectively.

CONCLUSION

This seminal study of GEM-A (abduction endurance) and GEM-B (bridging endurance) found both measures to be reliable and valid measures of gluteal endurance. Further examination of the GEMs in samples with different types of LBP or hip pain is recommended.

LEVEL OF EVIDENCE

3.

The effects of active break and postural shift interventions on recovery from and recurrence of neck and low back pain in office workers: A 3-arm cluster-randomized controlled trial

OBJECTIVES

To investigate the efficacy of active break and postural shift interventions aimed to reduce sitting discomfort on recovery duration and recurrence of neck and low back pain among high-risk office workers.

METHODS

A 3-arm cluster-randomized controlled trial with 12-month follow-up was conducted in 193 healthy but high-risk office workers. Participants in the intervention groups received custom-designed apparatus to facilitate either active breaks or postural shifts to reduce sitting discomfort at work. Participants in a control group received a placebo seat pad. Incidence of neck and low back pain with pain intensity and disability level was recorded monthly. Main outcome measures were recovery time and recurrent rate of neck and low back pain. Analyses were performed using log rank test and Cox proportional hazard models.

RESULTS

Median time to recovery in those receiving active break and postural shift interventions (1 month) was significantly shorter than those in the control group (2 months). Neck and low back pain recurrent rates for the active break, postural shift, and control groups were 21%, 18%, and 44%, respectively. Hazard rate (HR) ratios after adjusting for biopsychosocial factors indicated a protective effect of active break and postural shift interventions for neck and low back pain recurrence (HR_adj 0.22, 95% CI 0.06-0.83 for active breaks and HR_adj 0.35, 95% CI 0.16-0.77 for postural shift).

CONCLUSION

Active break and postural shift interventions shortened recovery time and reduced recurrence of neck and low back pain among high-risk office workers.

The clinical course of neck pain: Are trajectory patterns stable over a 1-year period?

BACKGROUND

Recent studies with data-driven approaches have established common pain trajectories. It is uncertain whether these trajectory patterns are consistent over time, and if a shorter measurement period will provide accurate trajectories.

METHODS

We included 1,124 patients with non-specific neck pain in chiropractic practice. We classified patients into pre-defined trajectory patterns in each of four quarters of the follow-up year (persistent, episodic, and recovery) based on measures of pain intensity and frequency from weekly SMS. We explored the shifts between patterns and compared patients with stable and shifting patterns on baseline characteristics and clinical findings.

RESULTS

785 (70%) patients were in the same pattern in 1st and 4th quarters. Patients with episodic pattern in the 1st quarter shifted to other patterns more frequently than patients in the other patterns. A stable persistent pattern was associated with reduced function and higher scores on psychosocial factors. There was a decreased frequency of patients classified as persistent pattern (75% to 63%) and an increase of patients in recovery pattern (4% to 15%) throughout the four quarters. The frequency of patients classified as episodic remained relatively stable (21% to 24%).

CONCLUSIONS

We found an overall stability of the persistent pattern, and that episodic patterns have more potential for shifts. Shifts mostly occurred between patterns closest in pain variation. The deviation in pattern distribution compared with previous studies suggests that the duration of measurement periods has an impact on the results of the classification.

SIGNIFICANCE

Having persistent pain and having very minor pain is relatively stable over one year, while episodic pain has more potential for shifts. The duration of measurement periods appears to have an impact on the results of the classification. The given criteria resulted in a reduced frequency of episodic pattern due to shorter measurement periods. Our findings contribute to improved understanding and predicting NP using a combination of patient characteristics and trajectory patterns.

Knowledge and management of low back pain as running-related injuries among Italian physical therapists: findings from a national survey

OBJECTIVES

To investigate the beliefs, knowledge, attitudes, behavior, and the clinical management procedures of the Italian physical therapists specialized in orthopedic manipulative physical therapy (OMPT) toward running and its correlation with low back pain (LBP).Design: A cross-sectional online survey was conducted in 2019, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.Setting: Italy.Participants: One thousand two hundred and eighteen Italian OMPTs.

METHODS

Survey Monkey software was used to administer the survey. The questionnaire was self-reported and included 26 questions. Descriptive statistics were used and related to the effective respondents for each question.

RESULTS

One thousand two hundred and eighteen questionnaires (60.9%) were included in the analysis. A considerable cohort of OMPTs working in private practice clinical settings (n = 845; 69.4%; 95% CI 66.7-71.9) has indicated running not to be a relevant risk factor for the onset of LBP (n = 806; 66.2%; 95% CI 63.4-68.8). Moreover, most of the participants (n = 679; 55.7%; 95% CI 52.9-58.5) adopted a combination of manual therapy techniques and therapeutic exercise for the management of runners with LBP.

CONCLUSIONS

Widespread knowledge of clinical and theoretical management of LBP in runners-patients has emerged among Italian OMPTs. The OMPTs' academic background agrees with the recent literature and therefore highlights the paucity of studies related to LBP as running-related injuries.

Low Back Pain Flares: How do They Differ From an Increase in Pain?

OBJECTIVE

The term flare is commonly used to describe low back pain (LBP) fluctuations, but individuals with LBP consider that it does not always correspond to increased pain. This case cross-over study aimed to: (1) determine the extent to which days with a flare identified according to a multidimensional definition (self-reported flare, SRF) corresponded to days with greater than average pain (pain-defined flare, PDF) and (2) to investigate whether physical and psychosocial features differ between PDF and SRF.

MATERIALS AND METHODS

Individuals with LBP for ≥3 months (N=126) provided data on flares, physical, and psychosocial features daily for 28 days using a smartphone application.

RESULTS

Most days with SRF (68%) did not have greater than average pain (ie, PDF), but most days with greater than average pain (64%) were reported as an SRF. On days with SRF-only all physical and psychosocial features were worse than nonflare days. SRF+PDF had lower sleep quality and higher pain intensity, fatigue, disability, pain catastrophizing, and fear avoidance than SRF-only. SRF+PDF had higher pain in the afternoon and evening, disability and pain catastrophizing than PDF-only. Self-efficacy at work and during leisure activities was worse on SRF+PDF days than SRF-only and PDF-only days.

DISCUSSION

These findings highlight that when individuals with LBP consider they have a flare, they do not always have greater than average pain, but have worse psychosocial features. This emphasizes that flare has broader dimensions than pain alone. Consideration of flare according to broad dimensions is important when investigating symptom fluctuations across different LBP trajectories.

Young adults with recurrent low back pain demonstrate altered trunk coordination during gait independent of pain status and attentional demands

Pain influences both attention and motor behavior. We used a dual-task interference paradigm to investigate (1) alterations in attentional performance, (2) the ability to switch task prioritization, and (3) the effect of attentional demand on trunk coordination during narrow-based walking in and out of a painful episode in individuals with recurrent low back pain (LBP). We tested twenty young adults with LBP both in and out of a painful episode and compared them to twenty matched back-healthy individuals. Participants simultaneously performed a narrow step width matching task and an arithmetic task, with and without instructions to prioritize either task. A motion capture system was used to record kinematic data, and frontal plane trunk coordination was analyzed using vector coding on the thorax and pelvis angles. Single-task performance, dual-task effect, dual-task performance variability, task prioritization switch, and trunk coordination were analyzed using paired t tests or repeated measures two-way ANOVAs. Results indicated that active pain has a detrimental effect on attentional processes, indicated by poorer single-task performance and increased dual-task performance variability for individuals with recurrent LBP. Individuals with LBP, regardless of pain status, were able to switch task prioritization to a similar degree as their back-healthy counterparts. Compared to the control group, individuals with recurrent LBP exhibited a less in-phase, more pelvis-dominated trunk coordination during narrow-based walking, independent of pain status and regardless of attentional manipulations. Thus, altered trunk coordination in persons with LBP appears to be habitual, automatic, and persists beyond symptom duration.

Are neuromuscular adaptations present in people with recurrent spinal pain during a period of remission? a systematic review

A plethora of evidence supports the existence of neuromuscular changes in people with chronic spinal pain (neck and low back pain), yet it is unclear whether neuromuscular adaptations persist for people with recurrent spinal pain when in a period of remission. This systematic review aimed to synthesise the evidence on neuromuscular adaptations in people with recurrent spinal pain during a period of remission. Electronic databases, grey literature, and key journals were searched from inception up to the 4^th of September 2020. Eligibility criteria included observational studies investigating muscle activity, spine kinematics, muscle properties, sensorimotor control, and neuromuscular performance in adults (≥ 18 years) with recurrent spinal pain during a period of remission. Screening, data extraction, and quality assessment (Newcastle-Ottawa Scale) were conducted independently by two reviewers. Data synthesis was conducted per outcome domain. A meta-analysis with a random-effects model was performed where possible. The overall strength of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation guidelines (GRADE). From 8292 records, 27 and five studies were included in a qualitative and quantitative synthesis, respectively. Very low level of evidence supports muscle activity changes in people with recurrent low back pain, especially greater co-contraction, redistribution of muscle activity, and delayed postural control of deeper trunk muscles. Reduced range of motion of the lumbar spine was also found. Meaningful conclusions regarding other outcome domains or people with recurrent neck pain could not be drawn. In conclusion, people with recurrent low back pain during a period of remission show muscle activity and spine kinematics adaptations. Future research should investigate the long-term impact of these changes, as well as adaptations in people with recurrent neck pain.

Exercise Is Medicine, But Perhaps Not for Preventing Low Back Pain: A Randomized Trial of Exercise and Education to Prevent Low Back Pain Recurrence

OBJECTIVE

To assess whether an exercise and education program was more effective than an education booklet for preventing recurrence of low back pain (LBP).

DESIGN

Randomized controlled trial.

METHODS

Participants aged 18 years or older who had recovered from an episode of LBP within the previous week were recruited from primary care practices and the community. Participants were randomized to receive either 12 weeks of exercise and education (8 supervised exercise sessions and 3 one-on-one sessions) or a control (education booklet). The primary outcome was time to recurrence of LBP during the 1-year follow-up. Times to recurrence of LBP leading to activity limitation, care seeking, and work absence were secondary outcomes. Data were analyzed with Cox regression using intention-to-treat principles.

RESULTS

We planned to include 160 participants but included 111 (exercise and education, n = 57; educational booklet, n = 54). At the end of the study period, data completeness was 84.2%. Thirty-six (63%) participants in the exercise and education group and 31 (57%) participants in the control group had a recurrence of LBP. There was no statistically significant difference in time to recurrence of pain between groups (hazard ratio = 1.09; 95% confidence interval: 0.7, 1.8). There was no statistically significant effect for any of the secondary outcomes.

CONCLUSION

Among people recently recovered from LBP, exercise and education may not meaningfully reduce risk of recurrence compared to providing an educational booklet. J Orthop Sports Phys Ther 2021;51(4):188-195. doi:10.2519/jospt.2021.10187.

Consistent differences in lumbar spine alignment between low back pain subgroups and genders during clinical and functional activity sitting tests

BACKGROUND

Subgroups of people with low back pain display differences in their lumbar alignment during tests from a clinical examination. However, it is unknown if subgroups display the same patterns during a functional activity test and if gender influences subgroup-related differences.

OBJECTIVES

Test if differences in lumbar alignment between two LBP subgroups are 1) present during a functional activity test of preferred sitting and 2) independent of gender.

DESIGN

Cross-sectional.

METHOD

154 participants with chronic low back pain were classified based on the Movement System Impairment Classification System by a physical therapist. Participants performed a functional activity test of preferred sitting and clinical tests of maximum flexed and extended sitting. 3D marker co-ordinate data were collected. Sagittal plane lumbar alignment, indexed by lumbar curvature angle, was calculated. A three-way mixed effect analysis of variance was used to examine effects of test, subgroup, gender, subgroup × test, gender × test and subgroup × gender.

RESULTS/FINDINGS

The lumbar rotation with extension subgroup [LCA = -8.0° (-9.5,-6.5)] displayed a more extended lumbar alignment than lumbar rotation [LCA = -5.9° (-7.4,-4.4)]. Women [LCA = -10.7° (-12.3,-9.2)] displayed a more extended lumbar alignment than men [LCA = -3.2° (-4.7,-1.7)]. There was a significant gender × test interaction (p = 0.01). The subgroup × test (p = 0.99) and subgroup × gender (p = 0.76) interactions were not significant.

CONCLUSIONS

LBP subgroup differences in lumbar alignment are present during preferred sitting. Gender-related differences in lumbar alignment are not driving subgroup differences. These findings highlight the need to use patient-specific clinical characteristics to guide treatment of a functional activity of preferred sitting limited due to low back pain.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

Background

The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.

Methods

A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O’Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.

Results

In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.

Conclusion

We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04031-z.

Determination of Biodex Balance System Cutoff Scores in Older People With Nonspecific Back Pain: A Cross-sectional Study

OBJECTIVE

The purpose of this study was to determine cutoff scores for the Biodex Balance System (BBS) and verify if they could be used to discriminate older people with nonspecific low back pain (NSLBP) with poor postural performance from those with good postural performance.

METHODS

This cross-sectional study included 52 participants with NSLBP older than 65 years. One level of stability (level 5; intraclass correlation ≥0.70) and 2 conditions (eyes open and eyes closed) were selected for the testing procedure. Anterior-posterior stability index (APSI), medial-lateral stability index (MLSI), and overall stability index (OSI) scores were calculated. The participants were classified into 2 groups: high risk of falling and low risk of falling. Both the receiver operating characteristic and the area under the curve were used to determine the best BBS cutoff values. Binary logistic regression analysis was used to investigate the ability of BBS scores to predict risk of falling.

RESULTS

BBS cutoff scores in the eyes-open condition (APSI = 2.60, MLSI = 1.95, OSI = 2.95) and eyes-closed condition (APSI = 3.05, MLSI = 2.17, OSI = 3.25) were found to be sensitive and specific in determining postural performance. Participants with index values lower than the cutoff scores had, respectively, 6.42, 4.20, and 3.72 times lower risk of falling in the eyes-open condition and 3.33, 5.50, and 3.00 times lower risk of falling in the eyes-closed condition. The predictive characteristics of the models for risk analysis were excellent and good to excellent.

CONCLUSION

Our study shows that BBS cutoff scores are sensitive and specific in distinguishing between poor and good postural performance in older people with NSLBP.

Neck pain patterns and subgrouping based on weekly SMS-derived trajectories

BACKGROUND

Neck and low back pain represent dynamic conditions that change over time, often with an initial improvement after the onset of a new episode, followed by flare-ups or variations in intensity. Pain trajectories were previously defined based on longitudinal studies of temporal patterns and pain intensity of individuals with low back pain. In this study, we aimed to 1) investigate if the defined patterns and subgroups for low back pain were applicable to neck pain patients in chiropractic practice, 2) explore the robustness of the defined patterns, and 3) investigate if patients within the various patterns differ concerning characteristics and clinical findings.

METHODS

Prospective cohort study including 1208 neck pain patients from chiropractic practice. Patients responded to weekly SMS-questions about pain intensity and frequency over 43 weeks. We categorized individual responses into four main patterns based on number of days with pain and variations in pain intensity, and subdivided each into four subgroups based on pain intensity, resulting in 16 trajectory subgroups. We compared baseline characteristics and clinical findings between patterns and between Persistent fluctuating and Episodic subgroups.

RESULTS

All but two patients could be classified into one of the 16 subgroups, with 94% in the Persistent fluctuating or Episodic patterns. In the largest subgroup, "Mild Persistent fluctuating" (25%), mean (SD) pain intensity was 3.4 (0.6) and mean days with pain 130. Patients grouped as "Moderate Episodic" (24%) reported a mean pain intensity of 2.7 (0.6) and 39 days with pain. Eight of the 16 subgroups each contained less than 1% of the cohort. Patients in the Persistent fluctuating pattern scored higher than the other patterns in terms of reduced function and psychosocial factors.

CONCLUSIONS

The same subgroups seem to fit neck and low back pain patients, with pain that typically persists and varies in intensity or is episodic. Patients in a Persistent fluctuating pattern are more bothered by their pain than those in other patterns. The low back pain definitions can be used on patients with neck pain, but with the majority of patients classified into 8 subgroups, there seems to be a redundancy in the original model.

An individualised self-management exercise and education program did not prevent recurrence of low back pain but may reduce care seeking: a randomised trial

QUESTION

What is the effect of a McKenzie-based self-management exercise and education program on the risk of recurrence of low back pain (LBP) and on the impact of LBP?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

262 adults recently recovered from an episode of LBP.

INTERVENTION

The experimental group received a McKenzie-based self-management exercise and education program delivered over two individual sessions of 30 to 45 minutes with a physiotherapist, approximately 2 weeks apart. The control group received a single advice session over the phone.

OUTCOME MEASURES

The primary outcome was time to first recurrence of an episode of activity-limiting LBP. Secondary outcomes included time to recurrence of any LBP, time to a recurrence causing care seeking and a composite measure of pain and function ('impact of LBP'). Participants were followed-up monthly for ≥ 12 months.

RESULTS

The estimated effect of the experimental intervention on the risk of recurrence of an episode of: activity-limiting LBP was HR 1.11 (95% CI 0.80 to 1.54), any LBP was HR 0.95 (95% CI 0.72 to 1.26), and LBP for which care was sought was HR 0.69 (95% CI 0.46 to 1.04). The quarterly estimates of the experimental intervention's effect on impact of LBP and their 95% CIs were all within 4 points above or below 0 (no effect) on this scale from 8 to 50.

CONCLUSION

This study's best estimate is that a McKenzie-based self-management exercise and education program does not produce a worthwhile reduction in the risk of an activity-limiting episode of LBP; however, modestly reduced or moderately increased risk cannot be ruled out. It may markedly reduce the risk of an episode of LBP resulting in care seeking, but does not have any worthwhile effect on the impact of LBP over 12 months.

TRIAL REGISTRATION

ACTRN12616000926437.

The RESOLVE Trial for people with chronic low back pain: statistical analysis plan

BACKGROUND

Statistical analysis plans describe the planned data management and analysis for clinical trials. This supports transparent reporting and interpretation of clinical trial results. This paper reports the statistical analysis plan for the RESOLVE clinical trial. The RESOLVE trial assigned participants with chronic low back pain to graded sensory-motor precision training or sham-control.

RESULTS

We report the planned data management and analysis for the primary and secondary outcomes. The primary outcome is pain intensity at 18-weeks post randomization. We will use mixed-effects models to analyze the primary and secondary outcomes by intention-to-treat. We will report adverse effects in full. We also describe analyses if there is non-adherence to the interventions, data management procedures, and our planned reporting of results.

CONCLUSION

This statistical analysis plan will minimize the potential for bias in the analysis and reporting of results from the RESOLVE trial.

TRIAL REGISTRATION

ACTRN12615000610538 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368619).

What Is the Personal Impact of Recurrences of Low Back Pain? Subanalysis of an Inception Cohort Study

OBJECTIVE

To investigate (1) the impact of low back pain (LBP) over the course of 1 year in people recently recovered from an episode of LBP, (2) whether the impact differs in people who do and do not experience a recurrence, and (3) the impact of LBP based on 3 definitions of a recurrence of LBP.

DESIGN

Cohort study.

METHODS

In 250 individuals recently recovered from LBP, the impact of LBP over the previous 3 months was assessed with the impact score, a multidimensional measure (range, 8-50), at 3, 6, 9, and 12 months. Recurrence of LBP was assessed monthly and defined as a recurrence of an episode of LBP, a recurrence of activity-limiting LBP, or a recurrence of LBP causing patients to seek care.

RESULTS

The median impact over 1 year was 11.5 points (interquartile range, 9.5-14.8). The impact was 15.2 points (95% confidence interval [CI]: 13.9, 16.3) for those who reported any recurrence and 11.1 points (95% CI: 10.6, 11.5) for those who did not. When comparing definitions of recurrence, those who had a recurrence that did not cause moderate activity limitation or result in care seeking had an overall impact of 12.7 points (95% CI: 11.6, 13.8). Participants who had recurrences of activity-limiting LBP but did not seek care, had an overall impact of 15.5 points (95% CI: 13.5, 17.6), and those who had recurrences of LBP for which health care was sought had an overall impact of 16.9 points (95% CI: 15.3, 18.4).

CONCLUSION

The average impact due to recurrence of LBP was low and dependent on the definition of recurrence. J Orthop Sports Phys Ther 2020;50(6):294-300. Epub 16 Apr 2020. doi:10.2519/jospt.2020.9345.

Back pain occurrence and treatment-seeking behavior among nurses: the role of work-related emotional burden

PURPOSE

To assess the association of back pain and treatment-seeking behavior for such pain with work-related emotional burden (regret about care), regret coping strategies, and physical burden among newly practicing nurses.

METHODS

We used data from the Impact of Care-related Regret Upon Sleep (ICARUS) cohort collected between 05.2017 and 07.2018 using web-based surveys (weekly for measures of emotional burden, physical burden and coping strategies, and monthly for back pain and seeking care). We investigated immediate associations and temporal influences between burdens and back pain with linear mixed models and cross-lagged Bayesian models, respectively. Coefficients were standardized to allow comparison between burdens. Logistic regression was used to examine the association of burdens with seeking care.

RESULTS

Among 105 nurses with an average follow-up of 3 months, 80 reported at least one episode of back pain. Neither physical nor emotional burdens had an immediate association with back pain. However, number of days with back pain in a given month was associated with an increase in both burdens during the previous month, with similar degrees of association (emotional: b = 0.24, physical: b = 0.21). Decision to seek treatment was associated with an increase in back pain frequency (OR 1.12, p = 0.04) and intensity (OR 1.80, p = 0.002) and a decrease in emotional burden (OR 0.95, p = 0.03). Coping strategies were associated neither with the occurrence of back pain nor with care-seeking.

CONCLUSION

While both emotional and physical burdens were associated with increased frequency of back pain the following month, emotional burden additionally showed a negative association with the decision to seek care.

The New Agenda for Neck Pain Research: A Modified Delphi Study

BACKGROUND

Though a large amount of research on neck pain has been conducted, no coordinated agenda has identified and addressed high-priority research questions.

OBJECTIVES

To identify and rank the neck pain research priorities of neck pain researchers.

METHODS

A total of 400 experts in the field of neck pain were invited to participate in this modified Delphi study. The study was conducted in 3 rounds. The first round aimed to identify the most important relevant questions that neck pain researchers should address. These questions were then categorized and ranked during the second and third rounds.

RESULTS

A total of 117 experts agreed to participate (29% response rate). A total of 15 neck pain research priorities were identified. The top 5 research priorities were to (1) establish effectiveness and cost-effectiveness of available treatments for neck pain, (2) translate research evidence into clinical settings, (3) identify the effectiveness of education and self-care in prevention and treatment of neck pain, (4) identify causal factors in the development of neck pain, and (5) define the natural course and prognostic factors in people with neck pain.

CONCLUSION

A new research-priority agenda was developed through a consensus process from a group of neck pain researchers. This agenda can be used as a guide for researchers and funding agencies to ensure that future research addresses the most important research questions in this area. J Orthop Sports Phys Ther 2019;49(9):666-674. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8704.

Importance of screening in physical therapy: vertebral fracture of thoracolumbar junction in a recreational runner

Running is one of the most popular sports worldwide. Studies suggest that 11%-85% of recreational runners have at least one running-related injury (RRI) each year, resulting in a reduction or interruption in training. A high risk for running-related injuries (RRIs) represents an important inconvenience counterbalancing the beneficial effects of running. RRIs primarily affect the joints of the lower limb and lumbar spine. Noteworthy, in some cases, the clinical presentation of signs and symptoms is confusing and may hide serious conditions; thus, clinicians have to pay special attention when potential factors arise, such as the presence of red flags. As reported in this case report, patients can present with low back pain (LBP) as a primary problem, mimicking a red flag such as a fracture of the spine. The aim of this case report was to describe a case of a recreational runner presenting with LBP as the sole symptom of an underlying thoracolumbar fracture.

Recurrence of low back pain is common: a prospective inception cohort study

QUESTIONS

How commonly and how quickly does low back pain reoccur in a cohort of people who have recently recovered from an episode of low back pain? What are the prognostic factors for a recurrence of low back pain?

DESIGN

Prospective inception cohort study with monthly follow-up for 12 months.

PARTICIPANTS

A total of 250 patients who had recovered from an episode of low back pain within the last month.

OUTCOME MEASURES

The primary outcome was days to recurrence of an episode of low back pain. Secondary outcomes were: days to recurrence of low back pain severe enough to limit activity moderately, and days to recurrence of low back pain for which healthcare was sought.

RESULTS

Within 12 months after recovery, 69% (95% CI 62 to 74) of participants had a recurrence of an episode of low back pain, 40% (95% CI 33 to 46) had a recurrence of activity-limiting low back pain, and 41% (95% CI 34 to 46) had a recurrence of low back pain for which healthcare was sought. The median time to recurrence of an episode of low back pain was 139 days (95% CI 105 to 173). Frequent exposure to awkward postures, longer time sitting (> 5 hours per day), and more than two previous episodes were predictive of recurrence of an episode of low back pain within 12 months (p < 0.01).

CONCLUSION

Recurrence of low back pain is very common, with more than two-thirds of individuals having a recurrence within 12 months after recovery. Prognostic factors for a recurrence include exposure to awkward posture, longer time sitting, and more than two previous episodes.

The effect of implicit theories of pain on pain and disability in people with chronic low back pain

BACKGROUND

Implicit theories of pain represent a socio-cognitive mechanism linked to important coping, emotional, and expressive reactions to chronic pain. Evidence suggests that chronic low back pain (CLBP) patients who hold an incremental theory of pain (i.e., view pain as a malleable) use more active coping strategies, display less pain behavior, and report lower levels of depression than those with an entity theory of pain (i.e., view pain as a fixed). However, a link between implicit theories of pain and symptoms of pain and disability in people with CLBP has not been established.

OBJECTIVES

This study investigated the relationship between implicit theories of pain and the level of pain and disability reported by people with CLBP.

DESIGN

Cross-sectional observational study.

METHODS

One hundred and two participants with CLBP completed an online survey distributed through social media channels. The online survey assessed pain intensity and pain-related disability (Chronic Pain Grade Scale), implicit theories of pain (Implicit Theory of Pain Scale), and perceived control over pain (Survey of Pain Attitudes control scale).

RESULTS

Participants with an incremental theory of pain reported significantly less pain and disability compared to those with an entity theory of pain (p < 0.001).

CONCLUSIONS

These findings suggest that implicit theories of pain may guide self-reported symptoms of pain and disability in a CLBP population. Prospective studies are required to confirm the relevance of these findings for risk of future low back pain, and to confirm whether this relationship changes with and without treatment.

A Definition of "Flare" in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus

Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although "flare" is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers' views, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions." Perspective: A multiphase process, incorporating consumers' views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.

The burden of low back pain among undergraduate physiotherapy students at the University of Zimbabwe: a cross-sectional study

OBJECTIVE

Globally, non-specific low back pain (NSLBP) is a common cause of morbidity in all people including physiotherapy students. However, no study has investigated the problem among undergraduate physiotherapy students in Zimbabwe. This study was conducted, therefore, to provide evidence of the prevalence, clinical characteristics and consequences of recurrent NSLBP among undergraduate physiotherapy students at the University of Zimbabwe.

RESULTS

The final sample had 90 participants, giving a study response rate of 97.8%. The median age of the participants was 22 years. The lifetime prevalence of NSLBP was 56.7% (n = 51) and the mean age of onset for NSLBP was 19.7 years (SD = 1.64 years). The 12-month prevalence of recurrent NSLBP was 38.9% (n = 35). Of the 35, 20 (57.1%) experienced at least three episodes in the last 12 months. Each episode lasted for 1-7 days in most participants (n = 31, 88.6%). The mean intensity of recurrent episodes was 3.37 (SD = 1.43) measured on Visual Analogue Scale. Only 7 (20%) experienced at least one functional limitation due to recurrent NSLBP. Additionally, only 2 (5.7%) sought medical treatment for the pain. However, 6 (17.1%) had to be absent from the university secondary to recurrent NSLBP.

Risk factors for low back pain and sciatica: an umbrella review

BACKGROUND

Low back pain (LBP) is a highly prevalent condition and it is associated with significant disability and work absenteeism worldwide. A variety of environmental and individual characteristics have been reported to increase the risk of LBP. To our knowledge, there has been no previous attempt to summarize the evidence from existing systematic reviews of risk factors for LBP or sciatica.

PURPOSE

To provide an overview of risk factors for LBP, we completed an umbrella review of the evidence from existing systematic reviews.

STUDY DESIGN

An umbrella review was carried out.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, PubMed PsychINFO, and CINAHL databases. To focus on the most recent evidence, we only included systematic reviews published in the last 5 years (2011-2016) examining any risk factor for LBP or sciatica. Only systematic reviews of cohort studies enrolling participants without LBP and sciatica at baseline were included. The methodological quality of the reviews was assessed independently by two review authors, using the Assessment of Multiple Systematic Reviews tool.

RESULTS

We included 15 systematic reviews containing 134 cohort studies. Four systematic reviews were of high methodological quality and 11 were of moderate quality. Of the 54 risk factors investigated, 38 risk factors were significantly associated with increased risk of LBP or sciatica in at least one systematic review and the odds ratios ranged from 1.26 to 13.00. Adverse risk factors included characteristics of the individual (eg, older age), poor general health (eg, smoking), physical stress on spine (eg, vibration), and psychological stress (eg, depression).

CONCLUSION

Poor general health, physical and psychological stress, and characteristics of the person increase risk for a future episode of LBP or sciatica.