Physical activity in daily life in patients with chronic low back pain

The key determinants of low back pain among lifestyle behaviors in adolescents: A cross-sectional study from Saudi Arabia

Establishing preventive measures and treatment strategies for adolescents with low back pain (LBP) may be greatly enhanced by fully grasping the complex interaction between LBP and lifestyle behaviors. The key objective of this study was to explore the possible associations between lifestyle behaviors and LBP among adolescents in Saudi Arabia. A cross-sectional study was conducted among high school students from 5 major regions in Saudi Arabia. Participants were enlisted for the research project between May and November 2021. To evaluate the presence/severity of LBP, physical activity, sedentary duration, sleep quality, nutrition, health responsibility, interpersonal relationships, spiritual growth, and stress management, a well-established web-based survey was employed. A total of 2000 students participated, with 57.9% reporting LBP. Students with LBP had lower scores on overall health-promoting lifestyle behaviors and all subscales, including physical activity, compared to those without LBP. Linear regression analysis revealed significant associations between sedentary duration and global sleep quality with pain severity among students with LBP. This study highlights the association between lifestyle behaviors and LBP among adolescents in Saudi Arabia. Promoting physical activity, reducing sedentary behavior, and improving sleep quality may be crucial in preventing and managing LBP in this population. Comprehensive strategies targeting lifestyle behaviors should be implemented to improve the well-being of adolescents and reduce the burden of LBP. Further research is needed to better understand the underlying mechanisms and develop effective preventive and treatment strategies for LBP among adolescents.

Measuring objective physical activity in people with chronic low back pain using accelerometers: a scoping review

Purpose

Accelerometers can be used to objectively measure physical activity. They could be offered to people with chronic low back pain (CLBP) who are encouraged to maintain an active lifestyle. The aim of this study was to examine the use of accelerometers in studies of people with CLBP and to synthesize the main results regarding the measurement of objective physical activity.

Methods

A scoping review was conducted following Arksey and O'Malley's framework. Relevant studies were collected from 4 electronic databases (PubMed, Embase, CINHAL, Web of Science) between January 2000 and July 2023. Two reviewers independently screened all studies and extracted data.

Results

40 publications out of 810 citations were included for analysis. The use of accelerometers in people with CLBP differed across studies; the duration of measurement, physical activity outcomes and models varied, and several limitations of accelerometry were reported. The main results of objective physical activity measures varied and were sometimes contradictory. Thus, they question the validity of measurement methods and provide the opportunity to discuss the objective physical activity of people with CLBP.

Conclusions

Accelerometers have the potential to monitor physical performance in people with CLBP; however, important technical limitations must be overcome.

Predicting resting energy expenditure: a critical appraisal

BACKGROUND

The most commonly used prediction models for resting energy expenditure (REE) are Harris-Benedict (1919), Schofield (1985), Owen (1986), and Mifflin-St Jeor (1990), based on height, weight, age and gender, and Cunningham (1991), based on body composition.

METHODS

Here, the five models are compared with reference data, consisting of individual REE measurements (n = 353) from 14 studies, covering a large range of participant characteristics.

RESULTS

For white adults, prediction of REE with the Harris-Benedict model approached measured REE most closely, with estimates within 10% for more than 70% of the reference population.

DISCUSSION

Sources of differences between measured and predicted REE include measurement validity and measurement conditions. Importantly, a 12- to 14-h overnight fast may not be sufficient to reach post-absorptive conditions and may explain differences between predicted REE and measured REE. In both cases complete fasting REE may not have been achieved, especially in participants with high energy intake.

CONCLUSION

In white adults, measured resting energy expenditure was closest to predicted values with the classic Harris-Benedict model. Suggestions for improving resting energy expenditure measurements, as well as prediction models, include the definition of post-absorptive conditions, representing complete fasting conditions with respiratory exchange ratio as indicator.

Prevalence of lower back pain and its associations with lifestyle behaviors among college students in Saudi Arabia

BACKGROUND

Lower back pain (LBP) is a common musculoskeletal disorder that may affect students' daily lives. Recent psychological research showed a relevant connection between LBP and multidimensional health. However, the association between LBP and lifestyle behavior has not been established, and improving knowledge in this area may help develop preventive strategies and optimize college students' quality of life.

METHODS

A cross-sectional study of 1420 college students in Saudi Arabia was conducted, and participants who attended Saudi Universities were recruited from May 2021 to November 2021. An established validated online survey assessed LBP, sleep quality, time spent sedentary (sedentary duration), health responsibility, physical activity, nutrition, spiritual growth, interpersonal relationships, and stress management. Generalized Linear Regression was used to assess the associations between LBP severity and lifestyle behaviors after controlling for covariates.

RESULTS

LBP was prevalent among college students from Saudi Arabia. Most of the sample were young (23.81 ± 6.02), and female (83.7%). There were significant differences between students with and without LBP regarding age, BMI, sex, marital status, pain severity, overall lifestyle behavior, health responsibility, physical activity, nutrition, stress management, and global sleep quality. After controlling for age, BMI, sex, and marital status, there were significant associations between pain severity and global sleep quality (ß=0.2, p < .001, CI: 16 to 0.24), and sedentary duration (ß=0.03, p = .01, CI:0.009 to 0.06).

CONCLUSIONS

This study helped define the prevalence of LBP in college students in Saudi Arabia and evaluated the association between LBP and lifestyle behaviors. The findings showed that students with higher levels of poor sleep quality or sedentary behavior had higher levels of pain. Promoting sleep quality and reducing sedentary behavior may help establish preventive strategies for LBP in college students.

Spine patient care with wearable medical technology: state-of-the-art, opportunities, and challenges: a systematic review

BACKGROUND CONTEXT

Healthcare reforms that demand quantitative outcomes and technical innovations have emphasized the use of Disability and Functional Outcome Measurements (DFOMs) to spinal conditions and interventions. Virtual healthcare has become increasingly important following the COVID-19 pandemic and wearable medical devices have proven to be a useful adjunct. Thus, given the advancement of wearable technology, broad adoption of commercial devices (ie, smartwatches, phone applications, and wearable monitors) by the general public, and the growing demand from consumers to take control of their health, the medical industry is now primed to formally incorporate evidence-based wearable device-mediated telehealth into standards of care.

PURPOSE

To (1) identify all wearable devices in the peer-reviewed literature that were used to assess DFOMs in Spine, (2) analyze clinical studies implementing such devices in spine care, and (3) provide clinical commentary on how such devices might be integrated into standards of care.

STUDY DESIGN/SETTING

A systematic review.

METHODS

A comprehensive systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) across the following databases: PubMed; MEDLINE; EMBASE (Elsevier); and Scopus. Articles related to wearables systems in spine healthcare were selected. Extracted data was collected as per a predetermined checklist including wearable device type, study design, and clinical indices studied.

RESULTS

Of the 2,646 publications that were initially screened, 55 were extensively analyzed and selected for retrieval. Ultimately 39 publications were identified as being suitable for inclusion based on the relevance of their content to the core objectives of this systematic review. The most relevant studies were included, with a focus on wearables technologies that can be used in patients' home environments.

CONCLUSIONS

Wearable technologies mentioned in this paper have the potential to revolutionize spine healthcare through their ability to collect data continuously and in any environment. In this paper, the vast majority of wearable spine devices rely exclusively on accelerometers. Thus, these metrics provide information about general health rather than specific impairments caused by spinal conditions. As wearable technology becomes more prevalent in orthopedics, healthcare costs may be reduced and patient outcomes will improve. A combination of DFOMs gathered using a wearable device in conjunction with patient-reported outcomes and radiographic measurements will provide a comprehensive evaluation of a spine patient's health and assist the physician with patient-specific treatment decision-making. Establishing these ubiquitous diagnostic capabilities will allow improvement in patient monitoring and help us learn about postoperative recovery and the impact of our interventions.

Relationship between physical activity and central sensitization in chronic low back pain: Insights from machine learning

BACKGROUND AND OBJECTIVES

Chronic low back pain (CLBP) is a leading cause of disability. The management guidelines for the management of CLBP often recommend optimizing physical activity (PA). Among a subsample of patients with CLBP, central sensitization (CS) is present. However, knowledge about the association between PA intensity patterns, CLBP, and CS is limited. The objective PA computed by conventional approaches (e.g. cut-points) may not be sensitive enough to explore this association. This study aimed to investigate PA intensity patterns in patients with CLBP and low or high CS (CLBP-, CLBP+, respectively) by using advanced unsupervised machine learning approach, Hidden semi-Markov model (HSMM).

METHODS

Forty-two patients were included (23 CLBP-, 19 CLBP+). CS-related symptoms (e.g. fatigue, sensitivity to light, psychological features) were assessed by a CS Inventory. Patients wore a standard 3D-accelerometer for one week and PA was recorded. The conventional cut-points approach was used to compute the time accumulation and distribution of PA intensity levels in a day. For the two groups, two HSMMs were developed to measure the temporal organization of and transition between hidden states (PA intensity levels), based on the accelerometer vector magnitude.

RESULTS

Based on the conventional cut-points approach, no significant differences were found between CLBP- and CLBP+ groups (p = 0.87). In contrast, HSMMs revealed significant differences between the two groups. For the 5 identified hidden states (rest, sedentary, light PA, light locomotion, and moderate-vigorous PA), the CLBP- group had a higher transition probability from rest, light PA, and moderate-vigorous PA states to the sedentary state (p < 0.001). In addition, the CBLP- group had a significantly shorter bout duration of the sedentary state (p < 0.001). The CLBP+ group exhibited longer durations of active (p < 0.001) and inactive states (p = 0.037) and had higher transition probabilities between active states (p < 0.001).

CONCLUSIONS

HSMM discloses the temporal organization and transitions of PA intensity levels based on accelerometer data, yielding valuable and detailed clinical information. The results imply that patients with CLBP- and CLBP+ have different PA intensity patterns. CLBP+ patients may adopt the distress-endurance response pattern with a prolonged bout duration of activity engagement.

The impact of lumbosacral alignment on lumbar mobility, functional disability and psychological wellbeing in office workers with chronic low back pain

Background/aims

The lumbosacral curvature of the spine has a special role in its mobility during weight-bearing activities. Office work is a sedentary role, which requires sitting for long durations, having a negative effect on spinal posture. Therefore, low back pain risk factors in office workers are different from other populations. The aim of this study was to examine the effect of lumbosacral joint angle on the lumbar mobility, functional disability, pain intensity and overall health in office workers with chronic low back pain.

Methods

A total of 116 male office workers with chronic low back pain (aged between 30–59 years) participated in this cross-sectional study. The lumbosacral radiography was used to divide the participants into two groups, according to the value of their lumbosacral joint angle: group A (lumbosacral joint angle <20°, n=61) and group B (lumbosacral joint angle group >20°, n=55). The lumbar mobility, functional disability, pain intensity and overall health issues of participants were measured.

Results

The functional disability and pain intensity of individuals in group A were significantly higher than group B (P<0.05). There was a significant decrease in the lumbar flexion and extension range of motion and activities of daily living of those in group A compared to group B (P<0.05). There was a significant increase in emotional health problems and impaired social activity of individuals in group A compared to group B (P<0.05). There were fair positive correlations between lumbosacral joint angle values and functional disability, pain intensity and social activity in office workers in group B (r=0.292, 0.036, 0.333 respectively).

Conclusions

A decreased lumbosacral joint angle increases functional disability and pain intensity, decreasing lumbar mobility and level of functionality. Furthermore, it reduces emotional health and social activity in participants with low back pain. Therefore, measuring the lumbosacral joint angle of patients with chronic low back pain during treatment may be useful to decrease their pain intensity and improve their functional disability and quality of life.

Chronic pain precedes disrupted eating behavior in low-back pain patients

Chronic pain is associated with anhedonia and decreased motivation. These behavioral alterations have been linked to alterations in the limbic brain and could explain the increased risk for obesity in pain patients. The mechanism of these behavioral changes and how they set in in relation to the development of chronic pain remain however poorly understood. Here we asked how eating behavior was affected in low-back pain patients before and after they transitioned to chronic pain, compared to patients whose pain subsided. Additionally, we assessed how the hedonic perception of fat-rich food, which is altered in chronic pain patients, related to the properties of the nucleus accumbens in this patients' population. We hypothesized that the accumbens would be directly implicated in the hedonic processing of fat-rich food in pain patients because of its well-established role in hedonic feeding and fat ingestion, and its emerging role in chronic pain. Accordingly, we used behavioral assays and structural brain imaging to test sub-acute back pain patients (SBP) and healthy control subjects at baseline and at approximately one-year follow-up. We also studied a sample of chronic low-back pain patients (CLBP) at one time point only. We found that SBP patients who recovered at follow-up (SBPr) and CLBP patients showed disrupted eating behaviors. In contrast, SBP patients who persisted in having pain at follow-up (SBPp) showed intact eating behavior. From a neurological standpoint, only SBPp and CLBP patients showed a strong and direct relationship between hedonic perception of fat-rich food and nucleus accumbens volume. This suggests that accumbens alterations observed in SBPp patients in previous works might protect them from hedonic eating disruptions during the early course of the illness. We conclude that disrupted eating behavior specifically sets in after pain chronification and is accompanied by structural changes in the nucleus accumbens.

Kinesiophobia in Elderly Polish Patients After Ischemic Stroke, Including Frailty Syndrome

INTRODUCTION

In patients after stroke, the relationship between the occurrence of kinesiophobia and the accompanying frailty syndrome, as well as the acceptance of the disease and the level of mood, has not been recognized so far. The aim of this study was to determine the prevalence of kinesiophobia in elderly Polish people after ischemic stroke, including the frailty syndrome and the associations between the prevalence of kinesiophobia and feelings of anxiety and degree of the illness acceptance.

METHODS

A cross-sectional study was used to achieve the study objectives. The study involved 152 hospitalized patients aged of minimum 60 (mean age 63), qualified for post-stroke rehabilitation, including 76 women and 76 men. The patients were divided into two groups, with kinesiophobia (119 persons) and without kinesiophobia (33 persons). The Tampa Scale of Kinesiophobia (TSK), the Tilburg Frailty Indicator (TFI), the Hospital Anxiety Depression Scale (HADS) and the Acceptance of Illness Scale (AIS) were used. Study results were calculated using MedCalc Software.

RESULTS

Kinesiophobia has been demonstrated in 78% of people after ischemic stroke. The values of TFI and HADS were higher in the patients with kinesiophobia (p<0.001). In patients with ischemic stroke, it was shown that the level of kinesiophobia increased with higher anxiety (p<0.001), higher total TFI score, (p<0.05), and a lower level of illness acceptance (p<0.001).

CONCLUSION

The occurrence of kinesiophobia in elderly Polish people after ischemic stroke is common and the determinants of its development are the coexistence of the frailty syndrome, anxiety and a low level of illness acceptance. In post-stroke patients, the presence of kinesiophobia should be considered, especially in the situation of comorbid frailty syndrome. The issue of kinesiophobia in patients after stroke requires further in-depth research, especially in the field of cognitive-behavioral prevention aimed at ways to reduce this phenomenon.

A Cumulative Impact of Psychological and Sensitization Risk Factors on Pain-Related Outcomes

OBJECTIVE

Risk constructs based on psychological risk factors (eg, pain catastrophizing, PC) and sensitization risk factors (eg, pressure pain threshold, PPT) are important in research and clinical practice. Most research looks at individual constructs but does not consider how different constructs might interact within the same individual. An evaluation of the cumulative impact of psychological and sensitization risk factors on pain-related outcomes may help guide us in the risk assessment of patients with pain conditions. The aim of this study is to evaluate the cumulative impact of these psychological (PC) and sensitization (PPT) risk factors on pain-related outcomes (activity avoidance, pain severity, and disability) considering covariates.

METHODS

We included 109 participants (70.60% women; mean ± SD age 53.6 ± 12.3 years) with chronic musculoskeletal pain for data analysis, who completed all measures of this study. Participants completed a single testing session that included measures of risk factors (PC and PPT) and pain-related outcomes (self-reported avoidance, functional avoidance, disability, and pain severity). Subgroups were constructed by dichotomizing of PC and PPT scores, resulting in four groups: (1) low catastrophizing and low sensitivity (N = 26), (2) high catastrophizing and low sensitivity (N = 27), (3) low catastrophizing and high sensitivity (N = 25), and (4) high catastrophizing and high sensitivity (N = 31).

RESULTS

One-way analysis of variance (ANOVA) revealed significant group differences (P < 0.05, η²  = 0.08 to 0.14) in all outcomes of this study (except functional avoidance), and post hoc analysis indicated the significant differences are between group 1 and 4. A cumulative impact is reflected by large effect sizes between group 1 and 4 (d = 0.8 to 1). The group 2 and 3 (one risk dimension groups: either high-PC or high-PPT) represent 47% of the total participants.

CONCLUSIONS

The study suggests both higher level of PC and pressure sensitivity have a cumulative impact on risk screening for pain-related outcomes, considering gender in functional avoidance (task-related outcome). A clinical presentation with high-PC (one dimension of risk) is not associated with high-PPT (another dimension of risk). This finding has important clinical and theoretical implications.

DNA Methylation and Brain-Derived Neurotrophic Factor Expression Account for Symptoms and Widespread Hyperalgesia in Patients With Chronic Fatigue Syndrome and Comorbid Fibromyalgia

OBJECTIVE

The epigenetics of neurotrophic factors holds the potential to unravel the mechanisms underlying the pathophysiology of complex conditions such as chronic fatigue syndrome (CFS). This study was undertaken to explore the role of brain-derived neurotrophic factor (BDNF) genetics, epigenetics, and protein expression in patients with both CFS and comorbid fibromyalgia (CFS/FM).

METHODS

A repeated-measures study was conducted in 54 participants (28 patients with CFS/FM and 26 matched healthy controls). Participants underwent a comprehensive assessment, including questionnaires, sensory testing, and blood withdrawal. Serum BDNF (sBDNF) protein levels were measured using enzyme-linked immunosorbent assay, while polymorphism and DNA methylation were measured in blood using pyrosequencing technology. To assess the temporal stability of the measures, participants underwent the same assessment twice within 4 days.

RESULTS

Repeated-measures mixed linear models were used for between-group analysis, with mean differences and 95% confidence intervals (95% CIs) shown. Compared to controls, serum BNDF was higher in patients with CFS/FM (F = 15.703; mean difference 3.31 ng/ml [95% CI 1.65, 4.96]; P = 0.001), whereas BDNF DNA methylation in exon 9 was lower (F = 7.543; mean difference -2.16% [95% CI -3.93, -0.83]; P = 0.007). BDNF DNA methylation was mediated by the Val66Met (rs6265) polymorphism. Lower methylation in the same region predicted higher sBDNF levels (F = 7.137, β = -0.408 [95% CI -0.711, -0.105]; P = 0.009), which in turn predicted participants' symptoms (F = 14.410, β = 3.747 [95% CI 1.79, 5.71]; P = 0.001) and widespread hyperalgesia (F = 4.147, β = 0.04 [95% CI 0.01, 0.08]; P = 0.044).

CONCLUSION

Our findings indicate that sBDNF levels are elevated in patients with CFS/FM and that BDNF methylation in exon 9 accounts for the regulation of protein expression. Altered BDNF levels might represent a key mechanism explaining CFS/FM pathophysiology.

Comparing Novel and Existing Measures of Sensitivity to Physical Activity Among People With Chronic Musculoskeletal Pain: The Importance of Tailoring Activity to Pain

OBJECTIVES

Increasing pain during physical activity is an important, but often poorly assessed, barrier to engaging in activity-based rehabilitation among people with chronic musculoskeletal pain. Preliminary work has addressed this problem by developing new clinical measures of sensitivity to physical activity (SPA). Indices of SPA are generated by evaluating how pain changes in relation to brief physical tasks. Three strategies have been identified for structuring SPA-related physical tasks (self-paced, standardized, and tailored). This cross-sectional study aimed to comparatively estimate the extent of the 3 SPA tasks' evoked pain responses, predictive value of pain severity and pain interference, and their underlying psychological and sensory constructs, among 116 adults with chronic musculoskeletal pain.

MATERIALS AND METHODS

Testing included questionnaires, quantitative sensory testing, and the 3 SPA measures (self-paced, standardized, and tailored). The primary analysis estimated the predictive value of each SPA measure for pain severity and pain interference. Correlational analyses were first conducted between all variables of interest to determine what variables will be included in the hierarchical regression analysis, which in turn was conducted for each outcome.

RESULTS

Analyses revealed that the tailored SPA index was most effective at evoking activity-related pain, was uniquely associated with temporal summation of pain, and was a unique predictor of pain and pain-related interference, even when controlling for established psychological and sensory risk factors.

DISCUSSION

This study further emphasizes SPA as an important and unique attribute of the pain experience and reveals the added value of using a tailored approach to assess SPA.

Subgrouping patients with chronic low back pain: What are the differences in actual daily life behavior between patients classified as avoider or persister?

BACKGROUND AND OBJECTIVE

The purpose of this study is to determine whether patients, classified by their treating consultant in rehabilitation medicine as avoider or persister, show differences in a large set of detailed outcomes of actual, objectively measured daily physical behaviour.

METHODS

In this explorative cross-sectional study, 16 patients were included; 9 patients were categorized as avoider and 7 patients as persister. Subjects wore the VitaMove activity monitor, a high-end accelerometry-based device that allowed automatic detection of a large set of body postures and motions. Physical behaviour was assessed in detail by total duration of body postures and motions as percentages of 24 hours, as well as by the number of sit-to-stand transfers, overall activity level, walking speed, and the distribution of bouts of physical activity and sedentary behaviour. Differences between groups were tested with the Mann Whitney U test.

RESULTS

There were no significant differences between groups in any of the physical behaviour outcomes.

CONCLUSIONS

Our study showed that activity-related behavioural style categorization by consultants in rehabilitation medicine is not expressed in objectively measured detailed outcomes of daily physical behaviour.

The Relevance of Dual Tasking for Improving Trunk Muscle Endurance After Back Surgery

OBJECTIVE

To determine the effect of dual tasking on trunk muscle endurance in patients after lumbar diskectomy.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital setting.

PARTICIPANTS

Individuals (N=14) undergoing primary lumbar diskectomy.

INTERVENTION

Using a randomized design on 2 separate days, muscle endurance was evaluated during prone bridging and Biering-Sorensen tests. Each test was randomly performed under 2 cognitive conditions: single task without cognitive condition and self-regulated dual task (ie, mathematical task).

MAIN OUTCOME MEASURES

The primary outcomes were time to failure and pain assessed by the visual analog scale from 0 to 100 mm. The secondary outcomes were kinesiophobia assessed by the Tampa Scale and disability assessed by the Oswestry Disability Index. Associations were tested using a repeated measures analysis of variance with relevant interaction test.

RESULTS

A significant interaction between condition, endurance tests, and kinesiophobia (P=.005) was found. The post hoc comparison showed positive effects between cognitive conditions in both endurance tests (prone bridging test: mean difference, 15.7s; 95% confidence interval [CI], 7.5-24s; P=.001; Biering-Sorensen test: mean difference, 7.9s; 95% CI, 1.9-14s; P=.014). The linear regression analysis between the Tampa Scale for Kinesiophobia and the difference of time to failure between cognitive conditions showed a positive correlation only during the Biering-Sorensen test (r=0.80; P=.001).

CONCLUSIONS

A self-regulated dual task increases trunk muscle endurance in patients after lumbar diskectomy. The results suggest that the difference observed in time to failure between the single task and dual task is associated with fear avoidance, especially during back extension. This strategy seems especially relevant for patients with high levels of fear avoidance and may be used to improve trunk muscle endurance.

Physical Activity and Health-Related Quality of Life in People With Back Pain: A Population-Based Pooled Study of 27,273 Adults

BACKGROUND

To investigate the association between moderate- to vigorous-intensity physical activity (MVPA) and health-related quality of life (HRQoL) in people with back pain.

METHODS

The sample comprised adults aged 16 years and older who participated in the Welsh Health Survey (2011-2015). The HRQoL was evaluated using the 36-item short form. Participants were categorized into 4 groups based on minutes per week of MVPA: inactive (no MVPA), insufficiently active (<150 min/wk), sufficiently active (≥150 and <300 min/wk), and very active (≥300 min/wk). The authors investigated the association between MVPA and HRQoL using generalized linear models and multiple linear regression.

RESULTS

Of the 74,578 adults in the survey cohorts, 27,273 participants diagnosed with back pain were included in the analyses. Consistent direct curvilinear associations between MVPA and HRQoL were demonstrated for all 36-item short form domains (P < .001), in both the minimally and fully adjusted models, with the highest scores observed for sufficiently active and very active participants. Compared with the inactive group, those who were insufficiently active; sufficiently active; and very active had an average difference of 6.31 (95% confidence interval, 5.70-6.92), 7.72 (95% confidence interval, 7.04-8.41), and 8.00 (95% confidence interval, 7.12-8.89) points in the overall HRQoL, respectively.

CONCLUSION

The authors found a consistent direct curvilinear association between MVPA and HRQoL.

Obesity and pain: a systematic review

BACKGROUND/OBJECTIVES

The current systematic review considered research published within the 10 years preceding June 2019, dealing with the topic of obesity and pain. Within the context of the complex biological and behavioral interrelationships among these phenomena, we sought to identify gaps in the literature and to highlight key targets for future transdisciplinary research. The overarching inclusion criteria were that the included studies could directly contribute to our understanding of these complex phenomena.

METHODS

We searched PubMed/Medline/Cochrane databases dating back 10 years, using the primary search terms "obesity" and "pain," and for a secondary search we used the search terms "pain" and "diet quality."

RESULTS

Included studies (n = 70) are primarily human; however, some animal studies were included to enhance understanding of related basic biological phenomena and/or where human data were absent or significantly limited.

CONCLUSIONS

Our overall conclusions highlight (1) the mechanisms of obesity-related pain (i.e., mechanical, behavioral, and physiological) and potential biological and behavioral contributors (e.g., gender, distribution of body fat, and dietary factors), (2) the requirement for accurate and reliable objective measurement, (3) the need to integrate biological and behavioral contributors into comprehensive, well-controlled prospective study designs.

Validity, reliability, and feasibility of the uSense activity monitor to register physical activity and gait performance in habitual settings of geriatric patients

OBJECTIVE

The aim of the study was to investigate the psychometric quality of a newly developed activity monitor (uSense) to document established physical activity parameters as well as innovative qualitative and quantitative gait characteristics in geriatric patients.

APPROACH

Construct and concurrent validity, test-retest reliability, and feasibility of established as well as innovative characteristics for qualitative gait analysis were analyzed in multi-morbid, geriatric patients with cognitive impairment (CI) (n  =  110), recently discharged from geriatric rehabilitation.

MAIN RESULTS

Spearman correlations of established and innovative uSense parameters reflecting active behavior with clinically relevant construct parameters were on average moderate to high for motor performance and life-space and low to moderate for other parameters, while correlations with uSense parameters reflecting inactive behavior were predominantly low. Concurrent validity of established physical activity parameters showed consistently high correlations between the uSense and an established comparator system (PAMSys^™), but the absolute agreement between both sensor systems was low. On average excellent test-retest reliability for all uSense parameters and good feasibility could be documented.

SIGNIFICANCE

The uSense monitor allows the assessment of established and-for the first time-a semi-qualitative gait assessment of habitual activity behavior in older persons most affected by motor and CI and activity restrictions. On average moderate to good construct validity, high test-retest reliability, and good feasibility indicated a sound psychometric quality of most measures, while the results of concurrent validity as measured by a comparable system indicated high correlation but low absolute agreement based on different algorithms used.

Feasibility, Validity, and Responsiveness of Self-Report and Objective Measures of Physical Activity in Patients With Chronic Pain

BACKGROUND

Accurate tools for measuring physical activity are important for monitoring patients with chronic pain. However, these tools have not been properly validated in this population.

OBJECTIVE

To determine the suitability of two physical activity measures for use in chronic pain populations.

DESIGN

Longitudinal observational study.

SETTING

Pain Management and Research Centre.

PARTICIPANTS

Sixty-four patients presenting to the Pain Management and Research Centre with chronic pain.

METHODS

Participants underwent a 3-week pain management program that included cognitive behavioral strategies, education, and multiple exercises sessions per day. Physical activity was measured by the Active Australia Survey and the Actigraph GT3X at the start and end of the program. Feasibility of the physical activity measures was assessed. Criterion validity and responsiveness between the measures was compared. Correlation of physical activity with self-rated global rating of change (GROC) scales in health were calculated.

MAIN OUTCOME MEASUREMENTS

Minutes per day spent in low, moderate, and vigorous physical activity; global rating of change.

RESULTS

Fifty-two percent (n = 33) and 78% (n = 50) of participants had valid Actigraph and Active Australia data, respectively, for both time points. For criterion validity and responsiveness correlations varied (rho = -.12-.52). All correlations between physical activity measures and GROC were small or negligible (rho ≤ .18).

CONCLUSION

Feasibility of the Actigraph was poor compared to the Active Australia Survey. The criterion validity and responsiveness of the Active Australia Survey to the Actigraph was inconsistent and the relationship of both these measures to clinical outcomes was poor. However, limitations due to missing data mean that further research is required.

LEVEL OF EVIDENCE

III.

Evaluating the novel added value of neurophysiological pain sensitivity within the fear-avoidance model of pain

BACKGROUND

The fear-avoidance model (FAM) is a leading theoretical paradigm for explaining persistent pain following musculoskeletal injury. The model suggests that as injuries heal, pain-related outcomes are increasingly determined by psychological, rather than physiological factors. Increasing literature, however, suggests that neurophysiological processes related to pain sensitivity also play an important role in chronicity. To date, there has been limited research that has specifically explored the role of pain sensitivity within the FAM. This study addresses this gap by evaluating whether clinical measures of pain sensitivity help explain FAM-related outcomes, beyond model-relevant psychological predictors.

METHODS

The study sample consisted of 80 adults with chronic and widespread musculoskeletal pain. Participants completed a single testing session that included measures of all of the major constructs of the FAM, including pain catastrophizing, pain-related fear, activity avoidance (self-report and functional measures), pain-related disability, depression and pain severity, as well as a battery of quantitative sensory testing that included measures of pressure pain threshold and temporal summation of mechanical pain across eight body sites.

RESULTS

A series of hierarchical regression analyses revealed that after controlling for the psychological predictors of the FAM, indices of pain sensitivity significantly predicted 4 of the 5 FAM-related outcomes (p < 0.05). Depression was the only outcome not significantly predicted by pain sensitivity. Interestingly, measures of pain sensitivity, but not FAM psychological factors, predicted the functional measure of activity avoidance.

CONCLUSIONS

These findings provide further evidence for the importance of neurophysiological factors within the FAM and have important clinical and theoretical implications.

SIGNIFICANCE

This study provides evidence for the unique and added value of neurophysiological factors within the Fear Avoidance Model of pain and for the importance of integrating both sensory and psychological factors within both theoretical paradigms and clinical management strategies.

Feasibility of high intensity training in nonspecific chronic low back pain: A clinical trial

BACKGROUND

Although low to moderate intensity exercise therapy is a predominant part of rehabilitation in nonspecific chronic low back pain (NSCLBP), effect sizes are small and optimal exercise modalities/intensities are unclear. Conversely, effects of high intensity training have not yet been investigated in this population.

OBJECTIVE

The aim of this study is to investigate the feasibility of high intensity training (HIT) and to explore the magnitude of the effects of a HIT program on exercise capacity and disease related outcome measures compared to conventional therapy for persons with NSCLBP.

METHODS

In this non-randomized controlled feasibility study, treatment satisfaction, adherence, disability, pain, physical activity, body composition, exercise capacity and self-reported motivation, were assessed in persons with NSCLBP, before (PRE) and after (POST) 6 weeks (12 sessions, 1.5 hours/session, 2 x/week) of high intensity cardiovascular (100% VO2Max) and high load resistance (80% 1RM) training (HIT, n= 10) and compared to average intensity/load (60% VO2max) conventional physical therapy (CON, n= 10).

RESULTS

At PRE, CON and HIT did not differ, except for gender ratio and lean mass. Compared to CON, HIT retained motivation to rehabilitate better (HIT: +3%; CON: -25%) and had higher therapy adherence (+16%) during the study course. No adverse events were noted in both groups. Whereas disability reduced in both groups (HIT: -10.4%; CON: -8.3%), peak workload (+7.0%), time to exhaustion (+9.5%), and activity level (+5.6%) only improved in HIT.

CONCLUSIONS

High intensity exercise therapy appears to be a feasible rehabilitation approach in NSCLBP. Outcomes improved following the HIT protocol, warranting the investigation of its effectiveness in future large scale RCT studies.

Objectively Measured Physical Activity and Low Back Pain in Japanese Men

BACKGROUND

There are several studies on the relationship between low back pain and physical activity. However, the results of these studies vary, and the relationship between them remains unclear. Therefore, we conducted a cross-sectional study to evaluate the association between objectively measured physical activity and low back pain in Japanese men.

METHODS

The study included 4022 Japanese men [average age: 47 (10) y]. Daily amount of moderate to vigorous physical activity and step counts were measured using an accelerometer. Low back pain, drinking and smoking, and lifestyle-related diseases were surveyed using a self-administered questionnaire. A logistic regression model was used to evaluate the relationship between physical activity and step counts with persistent low back pain after adjusting for confounders.

RESULTS

Persistent low back pain was reported in 428 participants. The multivariable-adjusted odds ratios of presenting persistent low back pain across quartiles of amount of moderate to vigorous physical activity were 1.00 (reference); 0.93 (95% confidence interval, 0.70-1.22); 0.97 (95% confidence interval, 0.74-1.28); and 0.67 (95% confidence interval, 0.50-0.90); P for linearity = .012.

CONCLUSION

We found a significant inverse relationship between objectively measured physical activity and persistent low back pain.

Does a Better Perfusion of Deconditioned Muscle Tissue Release Chronic Low Back Pain?

Non-specific chronic low back pain (nsCLBP) is a multifactorial condition of unknown etiology and pathogenesis. Physical and genetic factors may influence the predisposition of individuals to CLBP, which in many instances share a musculoskeletal origin. A reduced pain level in low back pain patients that participate in exercise therapy highlights that disuse-related muscle deconditioning may predispose individuals to nsCLBP. In this context, musculoskeletal pain may be the consequence of capillary rarefaction in inactive muscle as this would lower local tissue drainage and washing out of toxic waste. Muscle activity is translated into an angio-adaptative process, which implicates angiogenic-gene expression and individual response differences due to heritable modifications of such genes (gene polymorphisms). The pathophysiologic mechanism underlying nsCLBP is still largely unaddressed. We hypothesize that capillary rarefaction due to a deconditioning of dorsal muscle groups exacerbates nsCLBP by increasing noxious sensation, reducing muscle strength and fatigue resistance by initiating a downward spiral of local deconditioning of back muscles which diminishes their load-bearing capacity. We address the idea that specific factors such as angiotensin-converting enzyme and Tenascin-C might play an important role in altering susceptibility to nsCLBP via their effects on microvascular perfusion and vascular remodeling of skeletal muscle, inflammation, and pain sensation. The genetic profile may help to explain the individual predisposition to nsCLBP, thus identifying subgroups of patients, which could benefit from ad hoc treatment types. Future therapeutic approaches aimed at relieving the pain associated with nsCLBP should be based on the verification of mechanistic processes of activity-induced angio-adaptation and muscle-perfusion.

Association between objectively measured physical activity and body mass index with low back pain: a large-scale cross-sectional study of Japanese men

BACKGROUND

The relationship between the combination of physical activity (PA) and body mass index (BMI) with low back pain (LBP) is unclear. The present study offers a cross-sectional assessment of how combinations of PA and BMI are related to LBP in Japanese men.

METHODS

Participants were 4022 Japanese men (mean age = 47) who underwent regular clinical examinations. PA was measured using a uniaxial accelerometer and divided into tertiles (PA_high, PA_middle, PA_low). A self-administered questionnaire was used to report on persistent LBP experience, drinking and smoking habits, and any existing lifestyle diseases. After covariance adjustment, a logistic regression model was used to assess how combinations of PA and BMI are related to persistent LBP.

RESULTS

428 of the participants had persistent LBP. A clear negative dose-response relationship was found between PA levels and persistent LBP (P for linearity = 0.012). Regarding BMI, odd ratios were shown to be higher in the overweight/obese category (BMI ≥ 25 kg/m²) than for the normal weight category (BMI < 25 kg/m²). When the PA_high was taken as the reference in the normal weight category, odds ratios for PA_low and PA_middle in the normal weight category were shown to be high. Moreover, in the overweight/obese category, odd ratios for every fitness level were also high as for the normal weight category.

CONCLUSION

The present study showed that both PA and BMI are related to persistent LBP. Also, the prevalence of persistent LBP became higher when PA_low and high BMI are combined rather than the group of PA_high and low BMI combination.

Optimizing Cognitive Function in Persons With Chronic Pain

OBJECTIVES

Cognitive functioning is commonly disrupted in people living with chronic pain, yet it is an aspect of pain that is often not routinely assessed in pain management settings, and there is a paucity of research on treatments or strategies to alleviate the problem. The purpose of this review is to outline recent research on cognitive deficits seen in chronic pain, to give an overview of the mechanisms involved, advocate cognitive functioning as an important target for treatment in pain populations, and discuss ways in which it may be assessed and potentially remediated.

METHODS

A narrative review.

RESULTS

There are several options for remediation, including compensatory, restorative, and neuromodulatory approaches to directly modify cognitive functioning, as well as physical, psychological, and medication optimization methods to target secondary factors (mood, sleep, and medications) that may interfere with cognition.

DISCUSSION

We highlight the potential to enhance cognitive functions and identify the major gaps in the research literature.

A pilot study to determine the effect of one physical therapy session on physical activity levels for individuals with chronic low back pain

Background

A pilot study was conducted to quantify the effect size of changes in physical activity after of one session of physical therapy for individuals with chronic low back pain and to determine factors that predict daily sedentary activity time.

Methods

Fourteen subjects with at least 3 days of physical activity accelerometer data were analyzed before and after one session of physical therapy. Data was analyzed using 1-tailed, paired t-tests with level of significance set at 0.05. Effect sizes were computed using the baseline and post intervention mean differences divided by the baseline and post-intervention differences in the standard deviation.

Results

A nonsignificant reduction in steps-per-day and time spent performing sedentary activities, with increases in light and moderate–vigorous physical activity were found (effect size: 0.15–0.33). A nonsignificant decrease in daily sitting and standing time 1 week immediately following the physical therapy session and an increase in daily lying time (p = 0.03) (effect size: 0.23–0.69) were found.

Conclusion

One physical therapy session resulted in a small physical activity change for individuals with chronic low back pain. Baseline and post intervention levels of pain catastrophisation and perceptions of disability need to be explored in future studies to determine if these are factors that influence levels of physical activity change for these individuals Results are limited by the small sample size, however the ability to increase physical activity in this population may be of clinical relevance.

Trial Registration NCT02823756; June 30, 2016: Retrospectively Registered

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3006-x) contains supplementary material, which is available to authorized users.

Pain-Related Fear and Its Disabling Impact in Hypermobile Adolescents With Chronic Musculoskeletal Pain

Study Design Cross-sectional study. Background Chronic musculoskeletal pain (CMP) has a negative impact on physical functioning. During adolescence, joint hypermobility is a potential risk factor for developing CMP, and pain-related fear contributes to the persistence of CMP. Whether pain-related fear and hypermobility are related, and even reinforce each other, resulting in a stronger association with perceived level of disability, is still unknown. Objectives To evaluate whether pain-related fear has a stronger association with disability in hypermobile compared to nonhypermobile adolescents with CMP. Methods The study included 116 adolescents with CMP. The presence of hypermobility was assessed using the Beighton score. Measures of pain intensity, age, sex, and pain-related fear were collected and included in the multivariable model. Hierarchical regression analysis, with disability as the dependent variable, was used to examine the interaction between hypermobility and pain-related fear. Results Hypermobile adolescents with CMP do not have more pain-related fear compared to nonhypermobile adolescents with CMP. There was no interaction effect between hypermobility and pain-related fear in explaining disability (β = .20, P = .42). Similarly, perceived harmfulness of balance-related activities was not more strongly associated with disability in hypermobile adolescents with CMP. Conclusion The association of pain-related fear with the perceived level of disability is not more pronounced in hypermobile compared to nonhypermobile adolescents with CMP. J Orthop Sports Phys Ther 2017;47(10):775-781. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7282.

Mechanism evaluation of a lifestyle intervention for patients with musculoskeletal pain who are overweight or obese: protocol for a causal mediation analysis

INTRODUCTION

Low back pain (LBP) and knee osteoarthritis (OA) are highly prevalent and disabling conditions that cause societal and economic impact worldwide. Two randomised controlled trials (RCTs) will evaluate the effectiveness of a multicomponent lifestyle intervention for patients with LBP and knee OA who are overweight or obese. The key targets of this intervention are to improve physical activity, modify diet and correct pain beliefs. These factors may explain how a lifestyle intervention exerts its effects on key patient-relevant outcomes: pain, disability and quality of life. The aim of this protocol is to describe a planned analysis of a mechanism evaluation for a lifestyle intervention for overweight or obese patients with LBP and knee OA.

METHODS AND ANALYSIS

Causal mediation analyses of 2 two-armed RCTs. Both trials are part of a cohort-multiple RCT, embedded in routine health service delivery. In each respective trial, 160 patients with LBP and 120 patients with knee OA waiting for orthopaedic consultation will be randomised to a lifestyle intervention, or to remain part of the original cohort. The intervention consists of education and advice about the benefits of weight loss and physical activity, and the Australian New South Wales Get Healthy Service. All outcome measures including patient characteristics, primary and alternative mediators, outcomes, and potential confounders will be measured at baseline (T0). The primary mediator, weight, will be measured at 6 months post randomisation; alternative mediators including diet, physical activity and pain beliefs will be measured at 6 weeks post randomisation. All outcomes (pain, disability and quality of life) will be measured at 6 months post randomisation. Data will be analysed using causal mediation analysis with sensitivity analyses for sequential ignorability. All mediation models were specified a priori before completing data collection and without prior knowledge about the effectiveness of the intervention.

ETHICS AND DISSEMINATION

The study is approved by the Hunter New England Health Human Research Ethics Committee (13/12/11/5.18) and the University of Newcastle Human Research Ethics Committee (H-2015-0043). The results will be disseminated in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12615000490572 and ACTRN12615000478516; Pre-results.

Levels of physical activity in people with chronic pain

Background

People who suffer from chronic pain are thought to have lower levels of physical activity compared to healthy individuals. However, there is a lack of evidence concerning levels of physical activity in South Africans with chronic pain.

Objectives

To compare levels of physical activity in a South African sample of people with chronic pain compared to matched controls.

Methods

A cross-sectional study was conducted with 24 participants (12 with chronic pain and 12 in the control group matched for age, gender and residential area). Convenience sampling was used. The participants with chronic pain (12) were identified from the Groote Schuur Hospital, Chronic Pain Management Clinic (CPMC) waiting list and had not yet received any chronic pain management intervention. Healthy matched controls were selected from volunteers in the community. With the desired alpha level set at 0.05 and the power at 0.9, 45 participants were required to detect a minimum of a 50 per cent difference between groups in levels of physical activity as measured in steps per day using pedometers. The international physical activity questionnaire (IPAQ) and the brief pain inventory (BPI) were used as measures of physical activity and pain. Objective indicators of physical activity that were used included the 6-minute walk test (6MWT), repeated sit-to-stand test (RSST), 7 days of pedometry and body mass index (BMI).

Results

The chronic pain group performed significantly worse on the 6MWT (335 m [30-430] vs 680 m [430-795]; U = 0.5; p < 0.01) and on the RSST (17.9 s [11.83-105] vs 7.85 s [5.5-11.5]; U = 0; p < 0.01). The chronic pain group also had significantly lower scores on pedometry (mean daily: 2985.1 [32.8-13785.4] vs 6409.4 [4207.1-15313.6]; U = 35; p < 0.03). The BMI for the chronic pain group was significantly higher than matched controls (29.36 kg/m² [18.94-34.63] vs 22.16 kg/m² [17.1-30.86]; U = 34; p < 0.03).

Conclusion

Participants with chronic pain had a reduced capacity for physical activity. The pedometry results illustrate a range of maladaptive strategies adopted by those with chronic pain. The majority of people with chronic pain appear to avoid physical activity leading to greater disability as a result of immobility and muscle atrophy. However, a small subgroup appears to ignore their pain and push themselves physically despite their pain. This perseverance behaviour leads to further pain as a consequence of muscle and joint overuse. Both maladaptive behavioural responses result in further sensitisation of the central nervous system. The method used to target physical activity in these patients should be considered in treatment planning, specifically for physiotherapy.

Quantifying dimensions of physical behavior in chronic pain conditions

Background

Chronic pain, defined as persistent or recurrent pain lasting longer than 3 months, is a frequent condition affecting an important percent of population worldwide. Pain chronicity can be caused by many different factors and is a frequent component of many neurological disorders. An important aspect for clinical assessment and design of effective treatment and/or rehabilitation strategies is to better understand the impact of pain on domains of functioning in everyday life. The aim of this study was to identify the objectively quantifiable features of physical functioning in daily life and to evaluate their effectiveness to differentiate behavior among subjects with different pain conditions.

Method

Body worn sensors were used to record movement data during five consecutive days in 92 subjects. Sensor data were processed to characterize the physical behavior in terms of type, intensity, duration and temporal pattern of activities, postures and movements performed by subjects in daily life. Metrics quantifying these features were subsequently used to devise composite scores using a factor analysis approach. The severity of clinical condition was assessed using a rating of usual pain intensity on a 10-cm visual analog scale. The relationship between pain intensity and the estimated metrics/composite scores was assessed using multiple regression and discriminant analysis.

Results

According to the factor analysis solution, two composite scores were identified, one integrating the metrics quantifying the amount and duration of activity periods, and the other the metrics quantifying complexity of temporal patterns, i.e., the diversity of body movements and activities, and the manner in which they are organized throughout time. All estimated metrics and composite scores were significantly different between groups of subjects with clinically different pain levels. Moreover, analysis revealed that pain intensity seemed to have a more significant impact on the overall physical behavior, as it was quantified by a global composite score, whereas the type of chronic pain appeared to influence mostly the complexity of the temporal pattern.

Conclusion

The methodology described could be informative for the design of objective outcome measures in chronic pain management/rehabilitation programs.

Daily physical activities of patients with chronic pain or fatigue versus asymptomatic controls. A systematic review

Objective: To gain an insight into the daily physical activity levels of patients with chronic pain or fatigue compared with asymptomatic controls.

Data sources: MEDLINE, EMBASE, PsycINFO, Picarta, Cochrane Database of Systematic Reviews, reference tracking and a manual search of relevant journals.

Review methods: A systematic, computerized database search of the medical databases up to September 2006 was performed. In addition, a hand search of relevant journals was carried out. Appropriate studies reported on the daily physical activities of adult patients with chronic pain or fatigue and included an asymptomatic control group. Two reviewers independently carried out methodological quality assessment and data extraction. A qualitative analysis was performed.

Results: Twelve studies were included, involving five different syndromes. Results show large heterogeneity in methods used and syndromes investigated, which limited evidence. Eleven different methods were used to assess daily physical activities resulting in 16 different outcome parameters. There seem to be differences between the different syndromes, but results are not conclusive. Eight studies reported a lower physical activity level in patients compared with controls. There seems to be a difference in results between studies using objective versus those using subjective methods.

Conclusions: Results reported in the literature with respect to the activity level of patients with chronic pain or fatigue compared with controls were too heterogeneous to give sufficient evidence and were not conclusive.

Physical activity and health-related quality of life in chronic low back pain patients: a cross-sectional study

Background

The aim of the present study was to identify the relationship of physical activity (PA) and Health-Related Quality of Life (HRQoL) in patients suffering from low back pain (LBP).

Methods

The present evaluation was conducted as a cross-sectional study based on baseline data of an randomized controlled trial on the effectiveness of an intervention promoting PA. Patients answered a questionnaire on domain specific PA (GPAQ) and HRQoL (EQ-5D-5 L). Furthermore, sociodemographic and indication-specific variables as well as work-related aspects were assessed. Associations of PA and HRQoL were estimated by means of regression analysis: one regression model only included domain specific PA (model 1) and a second regression model additionally included further variables (model 2).

Results

412 patients completed the questionnaire. Model 1 showed opposed effects of workplace and leisure time PA: while workplace PA showed a negative association (β = −0.064; p = 0.04), a positive association of leisure time PA could be proved (β = 0.068; p = 0.01). Model 2 showed that only the variables “current work ability” (β = −0.030; p < 0.01) and “intensity of pain” (β = 0.104; p < 0.01) significantly contributed to explain the variance in HRQoL (model 2).

Conclusions

The present results indicate the necessity of a differentiation of workplace and leisure time PA in the context of assessing health-enhancing effects of PA in LBP patients. In the context of HRQoL it must be assumed that the relevance of PA might be overestimated. Further research should be performed on predictors of HRQoL and thereby particular attention should be paid on the patients’ work-related and indication-specific aspects.

The association between symptom severity and physical activity participation in people seeking care for acute low back pain

PURPOSE

To investigate the association between symptom severity and physical activity participation in people with acute non-specific low back pain (LBP).

METHODS

The sample included a total of 999 patients who presented to primary care with an acute episode of low back pain. Symptom severity, in terms of activity limitation and severity of pain; and physical activity participation before (habitual) and after pain onset were assessed using self-report questionnaires. All participants were interviewed within 14 days of pain onset.

RESULTS

At interview most of the participants (87.5 %) reported having moderate to extreme activity limitation due to back pain. There was a significant decrease in physical activity participation after pain onset (mean difference: -176 min, 95 % CI 327-400; p < 0.0001) but no association between habitual or change in physical activity participation and symptom severity was observed (p > 0.21).

CONCLUSION

Pain onset causes a significant and immediate decrease in physical activity participation, but this change does not seem to be associated with symptom severity.

A reappraisal of the deconditioning hypothesis in low back pain: review of evidence from a triumvirate of research methods on specific lumbar extensor deconditioning

OBJECTIVE

'Disuse' and 'Deconditioning' in relation to low back pain (LBP) are terms often used interchangeably. Discussions of 'disuse' refer to general physical inactivity, which evidence suggests does not differ between symptomatic and asymptomatic persons. 'Deconditioning' refers to a decrease in function, commonly both cardiovascular/aerobic fitness and muscular strength/endurance, again noting little difference. However, examination of decreased function relating specifically to lumbar extensor musculature deconditioning has yet to be examined, corroborating all possible methods. Thus, this review attempts to reappraise the deconditioning hypothesis in LBP, specifically considering lumbar extensor deconditioning.

METHODS

A literature review was conducted examining both cross-sectional and prospective data on specific lumbar extensor deconditioning and LBP. A narrative approach and 'snowballing' style literature search was used involving initial use of PubMed and Google Scholar databases searching up to December 2012. Included were studies utilizing the following three research methods, allowing specific induction of the role of such deconditioning; (1) strength/endurance testing of the isolated lumbar extensor musculature, (2) imaging and histochemical examination of the lumbar extensor musculature, and (3) fatigue testing of the lumbar extensor musculature using electromyography.

RESULTS/FINDINGS

Despite issues interpreting individual studies due to methods, the majority of evidence suggests LBP is associated with decreased strength/endurance, atrophy, and excessive fatigability of the lumbar extensors. Prospective studies also suggest lumbar extensor deconditioning may be a common risk factor predicting acute low back injury and LBP.

CONCLUSIONS

The hypothesis of specific lumbar extensor deconditioning as being a causal factor in LBP is presently well supported. It is by no means the only causative factor and further research should more rigorously test this hypothesis addressing the methodological issues highlighted regarding previous studies. However, its role suggests specific exercise may be a worthwhile preventative and rehabilitative approach.

Impact of chronic musculoskeletal pain on objectively measured daily physical activity: a review of current findings

SUMMARY Chronic pain affects a wide range of outcomes that are typically assessed using self-reported methodologies, which are susceptible to recall biases, current mood and pain intensity. Physical activity (PA) is an important component of the pain experience that can be objectively assessed with accelerometers, which are small, lightweight devices that measure the duration, frequency and intensity of PA over time. Accelerometry provides opportunities to compare actual and perceived PA, to design individually customized treatments, to monitor treatment progress, and to evaluate treatment efficacy. Thus, this technology can provide a more refined understanding of the relationships among symptoms, perceptions, mood, environmental circumstances and PA. The current paper examines patterns of PA in chronic musculoskeletal pain conditions and identifies potential clinical applications for accelerometry.

Improved physical activity in patients treated for chronic pain by spinal cord stimulation

The objective of this study was to objectively assess the physical activity of daily living in chronic pain patients treated with spinal cord stimulation (SCS). Changes in pain and spontaneous physical activity following SCS were evaluated under real life conditions. Five series of measurements were performed before the implant (baseline) and at one, three, six, and 12 months after the implantation of an SCS system. Compared to baseline values, physical activity increased consistently during the entire follow-up period. The time spent walking and standing was statistically increased after six months (p < 0.01) and the time spent lying decreased significantly (p < 0.001) at the same time. The average total walking distance increased up to 389% at 12 months, reaching statistical significance (p < 0.05) after three months. The stride length and the speed increased (p < 0.01) at all times. We conclude that the reduction in pain intensity due to SCS is associated with a progressive and sustained improvement in physical activity. j.

Assessment of physical activity by movement registration systems in chronic pain: methodological considerations

OBJECTIVES

Physical activity assessments in chronic pain research have mostly been based on self-report. However, earlier research indicated that chronic pain patients have difficulties in estimating their own daily life activity level. Movement registration systems have been introduced to overcome the limitations of self-reported measures. However, no uniform guidelines for researchers on how to analyze and interpret movement registration data in chronic pain exist. The aim of the study was to provide recommendations for physical activity assessment based on movement registration in patients with chronic pain.

METHODS

First, a systematic review of the procedures and data processing techniques used in movement registration for chronic pain patients will be performed. Second, it will be discussed whether the recommendations for physical activity assessment in healthy individuals are applied in chronic pain research. Last, recommendations regarding assessment procedure and data processing for using movement registration systems in future research in patients with chronic pain will be given.

RESULTS

In chronic pain literature, 27 articles on movement registration were identified. According to the recommendations for activity assessment in healthy individuals, the various descriptions of the assessment procedures in these articles were mostly limited. Especially, information regarding the minimal requirements for the assessment period and the method used for calculation of the final outcome variable were often lacking.

DISCUSSION

It is recommended that studies in chronic pain research explicitly apply and report the criteria that have been used to define an assessment day, the total assessment time, and the method for calculating the final test outcome.

Validity of activity monitors in health and chronic disease: a systematic review

The assessment of physical activity in healthy populations and in those with chronic diseases is challenging. The aim of this systematic review was to identify whether available activity monitors (AM) have been appropriately validated for use in assessing physical activity in these groups. Following a systematic literature search we found 134 papers meeting the inclusion criteria; 40 conducted in a field setting (validation against doubly labelled water), 86 in a laboratory setting (validation against a metabolic cart, metabolic chamber) and 8 in a field and laboratory setting. Correlation coefficients between AM outcomes and energy expenditure (EE) by the criterion method (doubly labelled water and metabolic cart/chamber) and percentage mean differences between EE estimation from the monitor and EE measurement by the criterion method were extracted. Random-effects meta-analyses were performed to pool the results across studies where possible. Types of devices were compared using meta-regression analyses. Most validation studies had been performed in healthy adults (n = 118), with few carried out in patients with chronic diseases (n = 16). For total EE, correlation coefficients were statistically significantly lower in uniaxial compared to multisensor devices. For active EE, correlations were slightly but not significantly lower in uniaxial compared to triaxial and multisensor devices. Uniaxial devices tended to underestimate TEE (−12.07 (95%CI; -18.28 to −5.85) %) compared to triaxial (−6.85 (95%CI; -18.20 to 4.49) %, p = 0.37) and were statistically significantly less accurate than multisensor devices (−3.64 (95%CI; -8.97 to 1.70) %, p<0.001). TEE was underestimated during slow walking speeds in 69% of the lab validation studies compared to 37%, 30% and 37% of the studies during intermediate, fast walking speed and running, respectively. The high level of heterogeneity in the validation studies is only partly explained by the type of activity monitor and the activity monitor outcome. Triaxial and multisensor devices tend to be more valid monitors. Since activity monitors are less accurate at slow walking speeds and information about validated activity monitors in chronic disease populations is lacking, proper validation studies in these populations are needed prior to their inclusion in clinical trials.

Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain

OBJECTIVE

To investigate whether physical activity (PA) levels and day patterns of sick-listed workers with chronic nonspecific musculoskeletal pain (CMP) admitted for multidisciplinary rehabilitation are different from those of workers with CMP.

DESIGN

Cross-sectional.

SETTING

Outpatient rehabilitation center and general community.

PARTICIPANTS

A convenience sample of sick-listed patients with CMP (n=27) referred for multidisciplinary pain rehabilitation, and a volunteer sample of workers with CMP (n=107; <5% sick leave in year before participation).

INTERVENTION

Participants wore an accelerometer for 5 to 7 consecutive days.

MAIN OUTCOME MEASURE

PA, expressed as activity counts. All analyses were corrected for confounders.

RESULTS

PA levels of workers with CMP were higher than those of sick-listed patients (P=.01). After correction for confounders, work status explained 3.5% of the variance observed in activity counts (F(change)=5.27, P=.024). In the mornings, group status significantly contributed to the variance in mean activity counts (F(change)=5.32, P=.02). In afternoons (F(change)=3.29, P=.07) and evenings (F(change)=2.41, P=.12), the effect of group status on PA level was nonsignificant. No significant interaction was observed between time and group status (Wilks' λ=.92, F(14,104)=.66, P=.80).

CONCLUSIONS

Workers with CMP have a higher PA level compared with sick-listed patients. The PA day pattern did not differ significantly between the 2 groups.

Patient-reported physical activity questionnaires: a systematic review of content and format

Background

Many patients with chronic illness are limited in their physical activities. This systematic review evaluates the content and format of patient-reported outcome (PRO) questionnaires that measure physical activity in elderly and chronically ill populations.

Methods

Questionnaires were identified by a systematic literature search of electronic databases (Medline, Embase, PsychINFO & CINAHL), hand searches (reference sections and PROQOLID database) and expert input. A qualitative analysis was conducted to assess the content and format of the questionnaires and a Venn diagram was produced to illustrate this. Each stage of the review process was conducted by at least two independent reviewers.

Results

104 questionnaires fulfilled our criteria. From these, 182 physical activity domains and 1965 items were extracted. Initial qualitative analysis of the domains found 11 categories. Further synthesis of the domains found 4 broad categories: 'physical activity related to general activities and mobility', 'physical activity related to activities of daily living', 'physical activity related to work, social or leisure time activities', and '(disease-specific) symptoms related to physical activity'. The Venn diagram showed that no questionnaires covered all 4 categories and that the '(disease-specific) symptoms related to physical activity' category was often not combined with the other categories.

Conclusions

A large number of questionnaires with a broad range of physical activity content were identified. Although the content could be broadly organised, there was no consensus on the content and format of physical activity PRO questionnaires in elderly and chronically ill populations. Nevertheless, this systematic review will help investigators to select a physical activity PRO questionnaire that best serves their research question and context.

Barcoding human physical activity to assess chronic pain conditions

BACKGROUND

Modern theories define chronic pain as a multidimensional experience - the result of complex interplay between physiological and psychological factors with significant impact on patients' physical, emotional and social functioning. The development of reliable assessment tools capable of capturing the multidimensional impact of chronic pain has challenged the medical community for decades. A number of validated tools are currently used in clinical practice however they all rely on self-reporting and are therefore inherently subjective. In this study we show that a comprehensive analysis of physical activity (PA) under real life conditions may capture behavioral aspects that may reflect physical and emotional functioning.

METHODOLOGY

PA was monitored during five consecutive days in 60 chronic pain patients and 15 pain-free healthy subjects. To analyze the various aspects of pain-related activity behaviors we defined the concept of PA 'barcoding'. The main idea was to combine different features of PA (type, intensity, duration) to define various PA states. The temporal sequence of different states was visualized as a 'barcode' which indicated that significant information about daily activity can be contained in the amount and variety of PA states, and in the temporal structure of sequence. This information was quantified using complementary measures such as structural complexity metrics (information and sample entropy, Lempel-Ziv complexity), time spent in PA states, and two composite scores, which integrate all measures. The reliability of these measures to characterize chronic pain conditions was assessed by comparing groups of subjects with clinically different pain intensity.

CONCLUSION

The defined measures of PA showed good discriminative features. The results suggest that significant information about pain-related functional limitations is captured by the structural complexity of PA barcodes, which decreases when the intensity of pain increases. We conclude that a comprehensive analysis of daily-life PA can provide an objective appraisal of the intensity of pain.