Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

Impact of exercise therapy with/without cognitive functional therapy on pain, Function, and biopsychosocial factors in chronic nonspecific low back pain

BACKGROUND

Exercise therapy (ET) is a well-established treatment for chronic low back pain. However, the combined effect of ET with cognitive functional therapy (CFT) on chronic nonspecific low back pain (CNLBP) remains under-investigated. This study investigated how these interventions, used together or separately, affected individuals with CNLBP.

METHODS

Sixty females (40-60 years) were allocated to ET, ET + CFT, and control groups. Both intervention groups received 24 sessions (3x/week) over 8 weeks. Functional disability, pain, lumbar pelvic motor control, and anxiety/depression were assessed before and after the intervention.

RESULTS

Fifty-one participants completed the study. The ET + CFT group showed greater improvements compared to both ET and control in all measured areas (functional disability, pain, motor control, anxiety/depression) (P < 0.05). However, both ET and ET + CFT groups improved significantly compared to control for all variables (P < 0.05).

CONCLUSIONS

Following eight weeks of intervention, both ET and ET + CFT improved functional disability, pain, lumbar pelvic motor control, and biopsychosocial indicators in individuals with CNLBP. Notably, while the combined intervention group (ET + CFT) showed greater improvements across most outcomes, it was significantly different from the exercise-only group only on the Kinesiophobia scale. These findings suggest that cognitive functional therapy may enhance the effectiveness of exercise therapy by addressing psychological factors, such as fear of movement, that contribute to pain and disability in CNLBP.

Unraveling the role of fear and avoidance behavior in chronic musculoskeletal pain: from theory to physical therapy clinical practice

BACKGROUND

Protective behaviors in the context of pain fostered by fear are helpful in acute traumatic pain to enable a person to protect their body from further injury and promote healing in the short term. However, protective behavior that is ongoing in the absence of tissue damage may contribute to the persistence of disability in people with musculoskeletal pain. Current evidence highlights the importance of addressing pain-related fear, fear of movement-related pain, and avoidance behavior in the management of people with chronic musculoskeletal pain. But, physical therapists find it challenging to make sense of and implement the evidence in their clinical practice. This issue partly stems from the pervasiveness of the biomedical model, which fails to address important psychological factors such as fear of movement-related pain and avoidance behavior and their role in chronic musculoskeletal pain. Despite a wider acceptance of the biopsychosocial model of care, physical therapists lack confidence and guidance on how to implement this model into practice.

OBJECTIVE

The aims of this masterclass are twofold: (1) to describe how the concepts/theory of fear learning can be applied in physical therapy practice for people with chronic musculoskeletal pain, (2) to illustrate the implementation of these concepts in clinical practice using an example of the management of a person with a chronic musculoskeletal pain condition.

DISCUSSION

We discuss how clinicians may identify and target fear of movement-related pain and avoidance behavior in clinical practice, with examples of how to understand and manage individuals with chronic musculoskeletal pain using an associative learning and behavioral framework.

Effectiveness of cognitive functional therapy for chronic spinal pain: a systematic review with meta-analysis

OBJECTIVE

To assess the effectiveness of cognitive functional therapy (CFT) in reducing disability and pain compared to other interventions in chronic spinal pain patients.

METHODS

Five databases were queried to October 2023 for retrieving randomized controlled trials (RCTs), including patients with chronic spinal pain and administering CFT. Primary outcomes were disability and pain. Secondary outcomes included psychological factors, quality of life, patient satisfaction, and adverse events. Two independent reviewers performed study selection, data extraction, risk of bias assessment (Cochrane RoB 2.0), and evidence certainty (GRADE approach). Random-effect models were used for meta-analyses. Clinical relevance was assessed with the smallest worthwhile effect.

RESULTS

Eight RCTs (N = 1228) for chronic low back pain (CLBP), one (N = 72) for chronic neck pain (CNP) were included. Compared to other conservative interventions, CFT may reduce disability (MD: -9.41; 95%CI: -12.56, -6.27) and pain (MD: -1.59; 95%CI: -2.33, -0.85 for CLBP) at short-term follow-up with probable to possible clinical relevance in CLBP and with low and very low evidence certainty, respectively. Similar results, with larger effect sizes, were observed for CFT compared to any unstructured or unsupervised minimal care treatments. Efficacy persisted in longer-term follow-ups, except for comparison with other conservative interventions. The CNP study showed positive results for CFT. Evidence certainty was low to very low. Sparse evidence was found for secondary outcomes.

CONCLUSION

CFT may offer clinically relevant benefits for CLBP, although the evidence remains mainly of low to very low certainty. Well-conducted studies, particularly in CNP and other spinal pain conditions are needed to strengthen these findings.

REGISTRATION

PROSPERO CRD42023482667.

Cognitive functional therapy for lower back pain: A meta-analytical assessment of pain and disability outcomes in randomized controlled trials

BackgroundCognitive functional therapy (CFT) aims to address low back pain (LBP) comprehensively by considering physical, psychological, and social factors.ObjectiveThe objective was to evaluate the effectiveness of CFT in reducing pain and disability in individuals with LBP over various time intervals.MethodA comprehensive literature search was conducted to identify relevant randomized controlled trials (RCTs) assessing the effects of CFT on LBP.ResultsIn this study, 1510 records were initially identified, and 7 studies were included in the analysis. Disability scores were significantly reduced after CFT had been applied for 6 to 8 weeks (SMD = - 0.46, 95% CI [- 0.74, - 0.19]), 12 weeks to 3 months (SMD = - 0.54, 95% CI [- 0.72, - 0.36]), 6 months (MD = - 5.82, 95% CI [- 9.82, - 1.82]), and 12 months (SMD = - 0.4, 95% CI [- 0.55, - 0.26]). There were also significant reductions in pain scores observed after 12 weeks to 3 months (SMD = - 0.49, 95% CI [- 0.68, - 0.3]), 6 months (MD = - 0.75, 95% CI [- 1.5, - 0.0001]), and 12 months (SMD = - 0.27, 95% CI [- 0.42, - 0.12]).ConclusionCFT showed potential for improving disability scores for individuals with LBP across various time intervals. However, its impacts on pain scores varied.

Ageing and higher BMI explain movement control impairment distinctly better than chronic pain and its contributing factors: A cross-sectional study of 161 subjects with chronic low back pain and 42 pain-free controls

BackgroundAssessment, diagnosis, and treatment of motor control impairments are among the most widely implemented management strategies for chronic low back pain (CLBP). Low back movement control tests described by Luomajoki et al. are reliable and valid for assessing the presence and severity of motor control impairment. However, very little is known about the importance of demographic and well-established CLBP contributing factors in explaining the presence and severity of any type of motor control impairment.ObjectiveThe study objectives were to evaluate the associations of the presence and the severity of movement control impairment with age, gender, BMI, CLBP and its intensity and duration, postural stability, self-reported central sensitization, kinesiophobia, and CLBP-related disability with logistic and ordinal regressions and Wald chi-squared tests.MethodsThis cross-sectional study included 161 subjects with CLBP and 42 pain-free controls. The study was carried out in single private chiropractic clinic.ResultsHigher age and BMI were distinctly greater associated with a higher presence and severity of movement control impairment compared to the pain-related factors, namely the CLBP or its intensity or duration, central sensitization, kinesiophobia, and CLBP-related disability.ConclusionsResults highlight the importance of considering demographic factors, such as age and BMI, when interpreting motor control impairment findings. Accordingly, the findings challenge the validity of testing motor control impairment in the management of CLBP.

Physiotherapists' delivery of cognitive functional therapy in clinical practice: perceived facilitators and barriers from a socioecological perspective

PURPOSE

Cognitive functional therapy (CFT) is a person-centred biopsychosocial intervention for chronic low back pain, with large sustained clinical and economic benefits. This study explored the experiences of physiotherapists delivering CFT in their usual clinical practice after being trained to competency for the RESTORE clinical trial.

MATERIALS AND METHODS

A qualitative study design was used. Fifteen primary care physiotherapists were interviewed (seven female, clinical experience 3-25 years). An inductive-deductive content analysis was used, including the Theoretical Domains Framework and socioecological model.

RESULTS

Facilitators and barriers were identified within and between individual, micro (clinical interface), meso (health service), and macro (health system) levels. Physiotherapists reported feeling competent and skilled delivering CFT. At the microsystem, this was influenced by time and their evolving professional identity. At the mesosystem, social support within the clinical community and positive patient outcomes facilitated CFT, while disunity in pain management across the health system and inadequate remuneration were barriers. Societal beliefs about pain, shifts in professional identity, and funding models influenced delivery at the macrosystem.

CONCLUSIONS

This study highlights multilevel facilitators and barriers that physiotherapists perceive when implementing CFT. Targeting these may help to optimise the implementation of this promising intervention, thereby contributing to better patient outcomes.

The interplay between pain and disease activity: personal models of pain beliefs and emotional representations in children and young people with juvenile idiopathic arthritis in a UK nationwide prospective inception cohort

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a group of childhood-onset inflammatory rheumatic conditions characterized by pain as one of the most common and distressing symptoms. This cross-sectional study aimed to investigate whether relationships between reported pain and disease activity in JIA affected beliefs about pain, known as "personal models."

METHODS

187 out of a possible 363 participants with JIA who completed questionnaires about function and pain perception were recruited through the Childhood Arthritis Prospective Study (CAPS). A pre-selected pain score threshold and validated disease activity score cut-offs were used to assign the participants into four groups: low pain/low disease, low pain/high disease, high pain/low disease, and high pain/high disease. Multivariable linear regressions examined associations between the groups and their "personal models."

RESULTS

Compared to participants with low pain/low disease, those with high pain/high disease and those with high pain/low disease were more likely to sense greater threat, have more negative emotional representations, and perceive less control over their pain. Participants with low pain/high disease had similar pain beliefs compared to those with low pain/low disease.

CONCLUSION

This is the first study to compare "personal models" of pain in JIA. Children and young people who experience high pain severity regardless of disease activity perceived high pain threat, low controllability, and negative emotional representations. This highlights the importance of considering and addressing personal models of pain at diagnosis, especially those who present high levels of pain.

The Czech version of the back pain attitudes questionnaire: Cross-cultural adaptation and measurement properties analysis

BackgroundAssessing attitudes and beliefs regarding low back pain is an integral component of a person-centered biopsychosocial approach to care.ObjectivesThis study aimed to translate and cross-culturally adapt the Back Pain Attitudes Questionnaire (Back-PAQ) and to evaluate the psychometric properties of both the full 34-item version and its shortened versions.MethodsFollowing recommended guidelines, cross-cultural adaptation process included forward and back translation, expert committee review, and pretesting using Three-Step Test-Interview. The psychometric properties evaluation involved physiotherapists and members of the general public, both with and without low back pain. Factor structure was analyzed using Principal Component Analysis, internal consistency was assessed using Cronbach's α, and test-retest reliability was measured using the Intraclass Correlation Coefficient (ICC).ResultsThe Back-PAQ was translated and culturally adapted to Czech (Back-PAQ-CZ). Five hundred and thirty-nine participants (299 physiotherapists; 240 members of general public) were included for the analysis. No meaningful factor structure was found for the 34-item Back-PAQ-CZ. However, a meaningful factor structure and acceptable Internal Consistency were found for the 10-item and 8-item versions. The test-retest reliability was excellent (ICC2,1 = 0.94), good (ICC2,1 = 0.87) and moderate to good (ICC2,1 = 0.76) for the 34-, 10- and 8-item version, respectively.ConclusionsThe Back-PAQ-CZ and its shortened versions should only be used with an awareness of identified limitations.

Cognitive functional therapy versus therapeutic exercises for the treatment of individuals with chronic shoulder pain: A protocol for a randomized controlled trial

INTRODUCTION

Shoulder pain is a debilitating musculoskeletal condition with functional, physical, and psychological impacts. Interventions for chronic shoulder pain should address the biopsychosocial model, with Cognitive Functional Therapy (CFT) emerging as a promising physiotherapy approach. CFT approaches the multidimensional nature of pain, integrating physical and cognitive aspects. To date, no study has assessed the effectiveness of CFT in individuals with chronic shoulder pain. Therefore, this randomized controlled trial aims to compare the effects of CFT to therapeutic exercises on pain intensity, disability, self-efficacy, sleep quality, biopsychosocial aspects, and central pain processing in individuals with chronic shoulder pain.

METHODS

This will be a randomized controlled trial, single-blinded with two parallel groups. Seventy-two individuals with chronic shoulder pain will be randomly assigned to one of two groups: CFT or Therapeutic exercise. The interventions will last 8 weeks, with the CFT group receiving therapy once a week and the therapeutic exercise group receiving sessions twice a week. The primary outcomes will be pain intensity and disability, while the secondary outcomes will include function, self-efficacy, sleep quality, biopsychosocial factors, perception of improvement/deterioration, and central pain processing. The outcome measures will be assessed at baseline, 4th week, end of treatment (8th week), and 12th-week follow-up.

CONCLUSION

The results of this study will contribute to understanding the effectiveness of CFT in treating individuals with chronic shoulder pain. Trial registration number: NCT06542666.

Key aspects concerning the role of emotion in the chronic pain experience

Pain and emotions are inherently connected, and this review presents contemporary findings on the pain-emotion connection. We address in what ways pain and emotions are related as well as how the link may be understood and targeted in treatment. Both pain and negative emotions are essential (and ancient) biological and motivational systems which share protective and regulatory functions. There is a marked co-occurrence between chronic pain and mental health conditions. One way to understand the pain-emotion connection, stressed by recent theoretical models, is that pain and emotions share cognitive and behavioral mechanisms that serve to downregulate these unpleasant inner states. Treatments targeting these shared regulatory mechanisms show promising results, but more research is needed on generalization, implementation and dissemination.

Considering Long-Acting Synthetic Cannabidiol for Chronic Pain: A Narrative Review

Chronic pain is prevalent and challenging to treat. Cannabinoids, in particular cannabidiol (CBD), have been evaluated as analgesics without the issues of tolerance or dependence. Side effects tend to be mild and infrequent. These products have multiple routes of administration and composition, and some are available over the counter, allowing pain patients to self-medicate. Most self-medicated CBD are plant-derived extracts administered as either oils, pills, or by inhalation. During the early 1960s, CBD was chemically synthesized for the first time, but it was not yet approved for medical use; synthetic CBD has been and continues to be studied in clinical trials for numerous indications, including chronic pain, neuropathic pain, and pain in cancer. However, studies are often small, populations heterogeneous, and some results are equivocal. Research is lively, with over 60 studies reported on ClinicalTrials.gov. Multimodal CBD therapy may hold promise, particularly in combination with palmitoylethanolamide. Greater patient education and training for physicians and other healthcare providers are needed along with more comprehensive studies. Considering the problem of chronic pain, further intensive study of synthetic CBD for pain control is warranted to meet this unmet clinical need. This is particularly important in the context of long-lasting administration methods that enable easy dosing and support long-term use for patients dealing with persistent and often debilitating symptoms.

Subgrouping People With Acute Low Back Pain Based on Psychological, Sensory, and Motor Characteristics: A Cross-Sectional Study

BACKGROUND

Clustering helps identify patient subgroups with similar biopsychosocial profiles in acute low-back pain (LBP). Motor factors are common treatment targets and are associated with disability but have not been included in acute LBP cluster development. This study aimed to identify subgroups of individuals with acute LBP based on motor, sensory and psychological characteristics and to compare these subgroups regarding clinical outcomes.

METHODS

Ninety-nine participants with acute LBP were recruited, and motor (bending range of motion [ROM], flexion relaxation), pain sensitivity (pressure-pain thresholds, temporal summation of pain) and psychological factors (pain catastrophising, kinesiophobia, self-efficacy) were measured, along with pain, disability and demographics.

RESULTS

Principal component analysis accounted for 66.03% of the variance. Four component scores were entered in a hierarchical linear clustering model, deriving 3 subgroups ('mild features' n = 39, 'sensorimotor' n = 35 and 'psychomotor' n = 25). Between-cluster comparisons revealed significant differences in motor, sensory and psychological variables (p < 0.05). Sensorimotor and psychomotor clusters had higher flexion-relaxation ratios (mean difference: > 0.2), greater disability (mean difference: > 7/100) and smaller ROM (mean difference: 7 cm) compared to the 'mild' group. The sensorimotor cluster mostly exhibited higher temporal summation of pain (mean difference: > 1.3/10) and lower pressure-pain thresholds (mean difference: > 1.2 kg/cm2) than 'mild' and psychomotor clusters. The psychomotor cluster showed higher kinesiophobia (mean difference: > 6/44) and pain catastrophising (mean difference: > 12/52) than 'mild' and sensorimotor groups.

CONCLUSION

Findings indicate 3 subgroups, suggesting that motor factors may add granularity to acute LBP clusters. Stratified care based on these subgroups may help refine treatment pathways for acute LBP.

SIGNIFICANCE STATEMENT

Including motor factors in cluster development adds a clinically relevant metric to describe people with acute LBP and generates insight into underlying mechanisms of motor adaptation. Longitudinal testing is required to see if these subgroups are differentially related to short- and long-term pain and disability.

Does motion sensor biofeedback augment change in movement? A longitudinal study of lifting spinal kinematics in people with chronic low back pain undergoing Cognitive Functional Therapy with and without biofeedback

BACKGROUND

Lifting is a functional movement commonly assessed and targeted in the treatment of people with low back pain (LBP).

OBJECTIVE

To investigate changes in spinal range of motion (ROM) and velocity during lifting in people with lifting-related LBP over the course of Cognitive Functional Therapy (CFT), and to compare these changes between CFT-only and CFT-with-biofeedback.

DESIGN

Longitudinal observational study.

METHOD

One hundred and forty-one people with lifting-related LBP received CFT and performed a lifting task prior to each treatment session. Measures included ROM and velocity from trunk and pelvis sensors independently and the intersensor angle. Multilevel models estimated the average amount of change and inter-individual variability. Time-group interaction was used to test the differences in the mean change between CFT-only and CFT-with-biofeedback.

RESULTS

During the 13-week intervention period, the average trunk and pelvis ROM increased significantly between week 1 and week 8 (10.6°, 95% CI: 5.9, 15.4; 10.4°, 95% CI: 6.9, 14.0), while the average intersensor ROM did not change over 13 weeks (-0.79°, 95% CI: -3.74, 2.16). The average trunk, pelvis and intersensor velocity increased significantly up to weeks 9 or 10 (17.8°/sec, 95% CI: 14.0, 21.6; 10.8°/sec, 95% CI: 8.3, 13.4; 6.0°/sec, 95% CI: 3.7, 8.3). There was no evidence for differences in change in ROM or velocity measures between CFT-only and CFT-with-biofeedback (P = 0.14-0.64).

CONCLUSIONS

People with lifting-related LBP demonstrated increases in trunk and pelvis ROM and all velocity measures but not intersensor ROM during lifting over the course of CFT. Biofeedback did not augment changes in lifting kinematics.

Relationships Between Changes in Forward Bending, Pain Catastrophizing, and Pain Self-Efficacy During Cognitive Functional Therapy for People With Chronic Low Back Pain

OBJECTIVE: To investigate whether improvements in forward bending were related to reductions in pain catastrophizing (PC) and improvements in pain self-efficacy (PSE) in people with chronic low back pain (CLBP) who were undergoing cognitive functional therapy (CFT). DESIGN: Longitudinal observational study. METHODS: Two hundred sixty-one participants with CLBP received CFT. Forward bending was assessed at each treatment session over 13 weeks (average of 4.3 time points per participant [range, 1-8]). Inertial measurement units placed on T12 and S2 measured spinal range of movement (ROM) and velocity. Participants completed the Pain Catastrophizing Scale and the Pain Self-Efficacy Questionnaire online at 0, 3, 6, and 13 weeks. Multivariate, multilevel models evaluated the associations between individual rates of change over time for 3 spinal movement measures (trunk velocity, trunk ROM, and lumbar ROM) as well as PC/PSE. RESULTS: Strong correlations were observed for increased trunk velocity with reduced PC (r = -0.56; 95% confidence interval [CI]: -0.82, -0.01) and increased PSE (r = 0.63; 95% CI: 0.18, 0.87). There was no evidence of an association between changes in trunk ROM and PC (r = -0.06; 95% CI: 0.38, 0.28) or PSE (r = 0.36; 95% CI: -0.27, 0.65) as well as no evidence of an association between lumbar ROM and PC (r = -0.07; 95% CI: -0.63, 0.55) or PSE (r = 0.16; 95% CI: -0.49, 0.69). CONCLUSION: Improvements in PC and PSE were strongly correlated with increased trunk velocity-but not trunk or lumbar ROM-in people with CLBP who were undergoing CFT. These findings are consistent with CFT that explicitly trains "nonprotective" spinal movement in conjunction with positively reframing pain cognitions. J Orthop Sports Phys Ther 2025;55(4):1-11. Epub 12 March 2025. doi:10.2519/jospt.2025.13114.

Self-suppressing behavioral patterns and depressive traits exacerbate chronic pain: Psychological trait assessment using the structured association technique method

This study investigated the relationship between psychological traits and chronic pain using the Structured Association Technique (SAT) method to evaluate psychological factors associated with chronic pain. The participants included 105 older adults (23 men, 82 women, mean age 80.82 years) who received rehabilitation services. Chronic pain severity was assessed using a numerical rating scale (NRS), and psychological traits were evaluated by SAT. In addition, maternal attachment experiences in childhood were examined. The NRS showed significant positive correlations with the self-suppressing behavioral pattern (S) scale (r =  0.31, p =  0.001), and the depression (D) scale (r =  0.31, p =  0.001). The proportion of participants with high scores on both the S and D scales (SD group) was notably higher in the high NRS group. Logistic regression analysis showed that the SD group had a higher odds ratio (OR =  8.469, p =  0.004) for severe chronic pain, suggesting that SD traits independently contribute to worse pain. In the SD group, the self-denial scale scores were high, and self-denial traits showed a negative correlation with maternal attachment experiences in childhood. This finding indicates that poor maternal attachment may enhance self-denial traits, which in turn indirectly worsen pain through their effects on S and D traits. The results of this study highlight the importance of S and D traits as psychological factors in chronic pain, particularly in Japanese populations, and suggest that assessing self-suppressing behavioral patterns may be beneficial for pain management. However, the cross-cultural validity of the SAT scales requires further investigation. SAT therapy may provide a comprehensive approach to the treatment and prevention of complex conditions influenced by psychological and social factors, including chronic pain.

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study

PURPOSE

Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study.

MATERIAL AND METHODS

This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study.

RESULTS

Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists.

CONCLUSION

The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

Persistence, not avoidance, is associated with low back pain-An observational cohort study

BACKGROUND

Low back pain (LBP) is increasingly understood as a long-lasting condition with a variable course. Avoidance and persistence behaviour have been described to mediate pain persistence by potentially linking psychosocial factors and biomechanics. The resulting maladaptive changes in musculoskeletal structures can result in movement control impairment (MCI). This investigation aimed to observe avoidance and persistence behaviour and MCI in participants with acute LBP over 1 year and explore their association with pain persistence.

METHODS

In this observational cohort study, 165 participants were assessed at five time points: ≤ 1 month (baseline), 2, 3, 6, and 12 months after the onset of acute LBP. Simultaneously collected clinical data such as self-reported outcomes at baseline for avoidance and persistence and assessments of MCI were filled in linear mixed-effects regression models.

RESULTS

The mixed-effects analysis revealed for the adjusted model that a one-point increase in persistence scores resulted in a 3.31-point increase in pain intensity while interacting with state anxiety over time (p = 0.05, 95% confidence interval 0.07-6.07). This effect was not found for avoidance behaviour at baseline (p = 0.21) and MCI.

CONCLUSIONS

The relationship between persistence and pain intensity throughout measurement suggests that continuing usual activities beyond pain, coupled with feelings of distress, may lead to persistent LBP. These results underscore the need for a therapeutic shift toward a multidimensional approach that considers the physical and psychological characteristics of persons with LBP. Screening for activity patterns in acute LBP is critical for providing tailored treatment and counselling.

SIGNIFICANCE STATEMENT

In acute low back pain (LBP), maintaining usual activities despite pain and distress can contribute to the continuation of LBP. Alongside a multidimensional approach that considers physical and psychological factors, attitudes toward daily activities are also important. Screening for both maladaptive and adaptive activity patterns in individuals with acute LBP is essential for effective LBP management, improving patient outcomes, and preventing persistent pain.

A multidisciplinary pain management program for patients with chronic low back pain: a randomized, single-blind, controlled, feasibility study

BACKGROUND

Multidisciplinary programs are the first recommendation for non-specific chronic low-back pain, but implementing this type of program is complicated to get up and running. The primary aim of this study was to assess the feasibility and appropriateness of the PAINDOC multidisciplinary program for subjects with chronic low-back pain. The secondary objectives were to evaluate the decrease in pain intensity, pain-related disability and pain catastrophizing, as well as the improvement in quality of life with this program. Furthermore, another of the secondary objectives was to calculate the sample size for a future randomized clinical trial.

METHODS

This study was conducted in a hospital pain unit using two successive recruitment waves. First, the feasibility outcomes (recruitment, completion, and drop-out rates) of a 5-month non-random prospective cohort (n = 227) were recorded. Then, the clinical outcomes (pain intensity, quality of life, disability, and pain catastrophizing) were recorded from a prospective, controlled, two-armed and single-blind feasibility study (ClinicalTrials.gov, NCT05974072). It included 41 participants that were randomly allocated to either the pharmacological treatment (n = 21) arm or PAINDOC program (n = 20) arm.

RESULTS

The recruitment rate was 66%, with the completion rate standing at 80.7% and the drop-out rate at 19.3%. Significant differences and a medium size effect were observed between groups in terms of pain intensity (p = .017, r = .408) at the 4-month follow-up. The intragroup analysis of the PAINDOC group revealed significant lessening in pain intensity (p = < 0.001) and improvements in quality of life (p = .030).

CONCLUSIONS

This study showed that the PAINDOC multidisciplinary program is a feasible treatment for patients with non-specific chronic low-back pain. Furthermore, the exploratory results of this study suggest that it could be an effective treatment to reduce pain intensity and improve on self-reported quality of life in these patients, although a future randomized clinical trial is needed to determine its effectiveness.

TRIAL REGISTRATION

NCT05974072 (registration date July 11, 2023; retrospectively registered; ClinicalTrials.gov).

The effectiveness of psychologically-informed physiotherapy for people with neck pain and the mediating role of illness perceptions: a replicated single-case experimental design study

PURPOSE

(1) To evaluate the effectiveness of personalised psychologically-informed physiotherapy in people with neck pain; (2) To explore the mediating role of changes in illness perceptions.

METHOD

In this replicated single-case study, 14 patients with non-specific neck pain at risk for chronicity received a personalised intervention addressing unhelpful illness perceptions and dysfunctional movement behaviour, according to principles of cognitive functional therapy. Outcomes included the mediating role of illness perceptions on overall effect, function, pain intensity and self-efficacy. Linear mixed models were used to analyse the data.

RESULTS

Repeated measurements (14-20 per patient), including a 3-months follow-up, showed a gradual improvement during and/or after psychologically-informed physiotherapy for overall effect, function, pain and to a lesser extent self-efficacy. Changes in each of the illness perception dimensions showed a mediation effect on overall effect, function and pain. When combining the dimensions "consequences," "personal control," "identity," "concern" and "emotional response," changes in illness perceptions explained approximately 35% of the improvement in overall effect.

CONCLUSION

Addressing unhelpful illness perceptions appears valuable in the management of patients with chronic or recurrent non-specific neck pain. Intervention effects extended beyond the treatment period, indicating that patients' improved understanding of their health condition continued to have a positive impact.

Exploring mental health approaches and curriculum in physiotherapy: an Australasian perspective

BACKGROUND

Exposure to mental health problems are becoming increasingly more frequent within physiotherapy. Physiotherapists recognize the need for a biopsychosocial approach, however their knowledge, assessment, and treatment skills specific to mental health problems requires further research.

PURPOSE

To profile the level of education and perception of education that physiotherapists have acquired specific to mental health problems; and to profile an understanding of the current practice of physiotherapists specific to mental health problems.

METHODS

An online survey addressed the aims of the study and collected data from physiotherapists in Australia and New Zealand (open between 20th of October 2022 to the 20th of March 2023).

RESULTS

139 respondents were included in the analysis. Physiotherapists had a perception that a significantly greater amount of coursework related to mental health needed to be included within their initial degree compared to what they received (mean difference of 20.0%, 95% CI: 17.5 to 22.5). This trend was evident irrespective of the degree level or the year of graduation. Higher perceived knowledge of anxiety (MD of 11.4, p = 0.001, ES: 0.5) and depression (MD of 11.8, p = 0.001, ES: 0.5) was evident in outpatient care physiotherapists. Lack of perceived knowledge is a reason for whether an assessment or treatment strategy is used with patients experiencing a mental health problem. Motivational interviewing and mindfulness were the most frequently used psychologically based techniques.

CONCLUSION

This study reveals the need to increase the amount of mental health and psychologically based techniques within Physiotherapy curriculum.

Psychologically Informed Physical Therapy Management of Chronic Musculoskeletal Pain in Culturally Diverse Populations: An Intervention Logic Model

Culturally and linguistically diverse (CALD) individuals are underrepresented in pain research, including studies of psychologically informed physical therapy (PIPT) for musculoskeletal pain. This perspective describes a conceptual framework for PIPT management of chronic musculoskeletal pain that identifies essential elements that can be culturally tailored to meet the needs of different CALD populations. Essential interventions, determinants of behavior change, and clinical outcomes were identified from studies of existing PIPT interventions for chronic pain. PIPT approaches shared the following essential interventions: 1) cognitive skill training, 2) general aerobic activity, 3) impairment-based therapeutic exercises, and 4) graded functional movement training. An intervention logic model was developed to conceptualize how these interventions might promote active coping behaviors and greater engagement in physical activity, therapeutic exercise, and functional mobility. The model included physical and cognitive-emotional processes that may contribute to behavioral changes that ultimately reduce pain-related disability. To illustrate the cultural tailoring of model constructs, we describe how intervention delivery and assessments were customized for Latino persons with chronic spine pain at a health center located near the United States-Mexico border. A literature review of sociocultural influences on the pain experience of Latino persons was conducted, and essential elements of the model were operationalized to ensure that therapeutic goals, language, content, and processes were compatible with Latino cultural beliefs, values, and behaviors. Future research using the proposed model to adapt and test PIPT interventions for other CALD populations may help identify shared and divergent mechanisms of treatment response for culturally tailored pain management programs. PERSPECTIVE: A novel conceptual framework may help inform the cultural tailoring of PIPT management approaches for chronic musculoskeletal pain by maintaining fidelity to essential treatment elements while also leveraging the unique sociocultural context of different CALD communities to improve health outcomes.

The comparison of Pilates with cognitive functional therapy in adults with chronic neck pain: a protocol for randomized controlled trial

BACKGROUND

Chronic Neck Pain is one of the main musculoskeletal problems in the general population that negatively affects the lives of patients. Its treatment can include various treatment methods, such as Pilates and Cognitive Functional Therapy. The purpose of this research was to investigate the effectiveness of Pilates in relation to Cognitive Functional Therapy in people with Chronic Neck Pain.

METHODS

This single-blind randomized controlled study included 60 patients with Chronic Neck Pain who were randomly divided into two groups (Group 1: Pilates, Group 2: Cognitive Functional Therapy). All patients will undergo 16 sessions over 8 weeks. Outcome measures (pain, disability, fear perception, functionality, quality of life, cervical range of motion, and neck muscle isometric strength) will be evaluated at baseline, at the end of the treatment (week 8) and three months after randomization (week 12). Outcome measures will be analyzed via random effects at the three assessment time points, and the interactions of the treatment groups with the assessment points will be included in the results of the fixed model.

DISCUSSION

This is the first Randomized Controlled Trial to compare the effectiveness of Pilates and Cognitive Functional Therapy in patients with chronic neck pain. The results of this research will provide information on the effectiveness of each intervention separately and whether one of the two can outperform the other.

The general public as well as physiotherapists evaluate spinal flexion as dangerous regardless of their own low back pain history

BACKGROUND

Maladaptive fear of movement in individuals with low back pain may be associated with worse clinical outcomes.

OBJECTIVE

To explore beliefs about the perceived dangers regarding different spinal postures within the Czech Republic.

DESIGN

Exploratory cross-sectional study including physiotherapists and members of the general public.

METHODS

Self-reported perceived safety/danger of "straight" and "flexed" spinal postures regarding 1) sitting, 2) lifting of light and 3) heavy object from the floor based on three pairs of photographs was measured using numeric rating scales (0-10, safe to dangerous) without any given context and in the context of low back pain. The sum of differences between the ratings of flexed and straight postures were used to calculate Bending Safety Beliefs Thermometer (BSBThermometer) total score potentially ranging -60‒60 (higher values indicates evaluation of flexed spinal postures as more dangerous in comparison to straight postures).

RESULTS

760 participants were included in the analysis. The mean BSBThermometer total score was 31.1 (SD 16.1) and higher scores were positively associated with being women (b = 14.8, 95% CI [9.9-19.8]); non-medical profession (b = 24.7, 95% CI [15.2-34.2]); age (b = 0.38, 95% CI [0.16-0.6]; and their interactions. There was no significant association with current low back pain status or history of low back pain.

CONCLUSIONS

On average, participants evaluated "flexed" spinal postures as significantly more dangerous when compared with "straight" spinal postures, with only subgroups of physiotherapists scoring lower than the general public. Clinically, these beliefs could be targeted by individualized education, exposure-based interventions and public campaigns; however, further research is required.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Research hotspots and frontiers in non-specific low back pain: a bibliometric analysis

Background

Extensive research has been conducted worldwide on non-specific low back pain (NSLBP), some researchers published a bibliometric analysis of NSLBP in 2020, but there have been no supplements or updates since then. Therefore, this study aimed to analyze the research hotspots and frontiers in NSLBP over the last decade.

Methods

Primary sources on NSLBP were obtained from the Web of Science Core Collection database from 2014 to 2023. CiteSpace V6.2. R7 (64-bit) and VOSviewer 1.6.19 software were used to analyze the number and centrality of journals, countries, institutions, authors, references, and keywords, and the functions of co-occurrence and clustering were applied to draw a visual knowledge map.

Results

In the past decade, the annual publication volume of studies on NSLBP has shown an overall upward trend year by year, with obvious temporal stages and great development potential. In total, 2,103 articles contained six types of literature, with the highest proportion being original research articles (1,633 articles, 77.65%), published in 200 journals. BMC Musculoskeletal Discourses (90 articles, 4.28%) had the highest number of publications, and the British Medical Journal had the highest impact factor (105.7). Furthermore, the United States of America (329 articles, 15.64%) had the highest publication volume, the University of Sydney (139 articles, 6.61%) was the research institution with the highest production, Maher, Chris G (36 articles, 1.71%) was the author with the most published articles, and Hoy, D (571 articles, 27.15%) was the most frequently cited author. The most cited of articles is "Non-specific low back pain" published in the LANCET, with 1,256 citations.

Conclusion

This article summarizes the current research status of NSLBP and predicts future research hotspots and frontiers. In recent years, adolescents have become a high-risk group for NSLBP. Pain neuroscience education, motor control, spinal manipulative therapy, and acupuncture are effective means to treat NSLBP. Biomechanics and trunk muscles as entry points are effective ideas for the treatment of NSLBP pain. Furthermore, anxiety, neck pain, non-specific musculoskeletal pain, fibromyalgia, and musculoskeletal disorders are diseases that are closely related to NSLBP. In the future, attention should be paid to the design of research plans, increasing the research intensity of randomized controlled trials, strengthening follow-up, and the timely updating of guidelines, which will result in higher quality and high-level scientific evidence for research on NSLBP.

"Every patient teaches you something new": experiences of physiotherapists delivering cognitive functional therapy for chronic, disabling low back pain in a randomised controlled trial

PURPOSE

Cognitive functional therapy (CFT) is an individualised person-centred biopsychosocial intervention that demonstrated large and sustained clinically important improvements in people with chronic, disabling low back pain (LBP) in the RESTORE randomised controlled trial. This study aimed to explore physiotherapists' experiences of delivering CFT in the RESTORE trial.

MATERIALS AND METHODS

Cross-sectional qualitative design using reflexive thematic analysis with interviews of 15 treating physiotherapists (3-25 years experience) across Perth and Sydney.

RESULTS

The overarching theme was "Driving on P(probationary)-plates." The probationary driver analogy encompassed feelings of being newly competent, gaining experience, and refining competencies. Four themes were developed: "Sharing the journey of transformational change," "Refining new competencies," "Navigating patient complexity," and "Balancing patient care with trial-related processes." Physiotherapists described the life-changing improvements and re-engagement with valued activities of their patients under the theme of "Sharing the journey of transformational change." "Refining new competencies" described the continued enhancement of physiotherapists' new competencies towards an individualised and collaborative approach.

The experiences of physiotherapists trained to deliver individualised, person-centred biopsychosocial care within an RCT can be likened to being a probationary driver. Experiential learning, ongoing support, and opportunities to navigate challenges with complex patients were important aspects of the journey towards mastery.

What are the predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears? Gaining expert consensus using an international e-Delphi study

BACKGROUND

Massive irreparable rotator cuff tears can cause significant shoulder pain and disability. Treatment options include physiotherapy or surgery, with a lack of research comparing treatment options. For physiotherapy there is uncertainty about which patients will have a successful or unsuccessful response to treatment and a lack of consensus on what constitutes the best physiotherapy programme. With these significant gaps in the research, it is challenging for clinicians seeing patients with massive irreparable rotator cuff tears to advise on what is their best treatment pathway.

METHODS

A three round Delphi study was conducted with expert shoulder physiotherapists and orthopaedic surgeons to gain consensus on the important factors associated with response to physiotherapy in this patient population. Round 1 was an information-gathering round to identify predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears. Rounds 2 and 3 were consensus-seeking rounds on the importance and modifiability of the predictors. Consensus criteria were determined a priori using median, interquartile range, percentage agreement and Kendall's Coefficient of Concordance.

RESULTS

Participants were recruited April-October, 2023. 88 experts participated in Round 1 and of these, 70 completed Round 3 (79.54%). In Round 1, content analysis of 344 statements identified 45 predictors. In Round 2, 29 predictors reached consensus as important and 2 additional predictors were identified. In Round 3, of the 31 predictors from Round 2, 22 reached consensus as important and 12 of these reached consensus as modifiable by physiotherapists. Both patient factors and clinician factors from a broad range of domains reached consensus: biomechanical, psychological, social, co-morbidities, communication / healthcare interactions and pain.

CONCLUSIONS

The results of this Delphi study suggest that clinicians assessing patients with massive irreparable rotator cuff tears should assess across all these domains and target the modifiable factors with interventions. Particular emphasis should be placed on optimising modifiable clinician factors including therapeutic alliance, comprehensive explanation of the condition and collaborative and realistic goal-setting. These in turn may influence modifiable patient factors including patient expectations, engagement with the physiotherapy programme, motivation and self-efficacy thus creating the ideal environment to intervene on a biomechanical level with exercises.

Patient and staff perspectives on pain treatment experiences in a community clinic serving under-resourced older adults

AIMS

Chronic pain affects up to 37.8% of older adults with higher prevalence among those in under-resourced communities. While there are many treatments for chronic pain, there are complexities to treating under-resourced older adults in community clinics, including multimorbidity, barriers to treatment access, and varying degrees of openness to different treatment approaches. Understanding patient and clinic staff perceptions of treatment options for chronic pain is critical for implementing treatment approaches that will work sustainably in the community. This study aimed to understand clinic staff and patients' perspectives on chronic pain treatment experiences.

METHODS

Focus groups and individual interviews were analyzed using a hybrid inductive-deductive approach.

RESULTS

Themes are: (1) Limited patient and clinic resources and availability affecting pain treatment experiences (e.g., copays, transportation challenges, and conflicting responsibilities), (2) Discrepancies in patient and staff approaches to treatment and the importance of trialing different pain management techniques to alleviate pain (e.g., trialing multiple treatments with varied success), and (3) Conflict between patients' desire for pain elimination vs. staffs' focus on symptom reduction and function (e.g., patient-staff disconnect).

CONCLUSIONS

These findings are important for determining how treatments can best fit the needs of under-resourced older adults with chronic pain.

Patients with worse disability respond best to cognitive functional therapy for chronic low back pain: a pre-planned secondary analysis of a randomised trial

QUESTION

Do five baseline moderators identify patients with chronic low back pain who respond best to cognitive functional therapy (CFT) when compared with usual care?

DESIGN

Secondary analysis of the RESTORE randomised controlled trial.

PARTICIPANTS

A total of 492 adults with low back pain for > 3 months with at least moderate pain-related activity limitation.

INTERVENTION

Participants were allocated to CFT alone or CFT plus biofeedback; these two groups were combined for this secondary analysis. The control group was usual care.

OUTCOME MEASURES

The outcome was activity limitation measured using the Roland Morris Disability Questionnaire (RMDQ) at 3, 6, 13, 26, 40 and 52 weeks. Investigated effect modifiers were baseline measures of activity limitation, cognitive flexibility, pain intensity, self-efficacy and catastrophising.

RESULTS

Baseline levels of activity limitation and, potentially, cognitive flexibility were associated with different effects of CFT treatment, while pain intensity, self-efficacy and catastrophising were not. Patients who had higher baseline activity limitation had greater treatment effects at 13 and 52 weeks. A person with a baseline RMDQ score of 18 (90th percentile) would on average be 6.1 (95% CI 4.8 to 7.4) points better at 13 weeks if they received CFT compared with usual care. However, a person with a baseline score of 7 (10th percentile) would on average be 3.6 (95% CI 2.6 to 4.6) points better at 13 weeks.

CONCLUSION

The finding that CFT is most effective among patients who are most disabled and incur the greatest burden strongly suggests that CFT should be considered as a treatment for this group of patients.

REGISTRATION

ACTRN12618001396213.

The effectiveness of cognitive functional therapy on patients with chronic neck pain: A systematic literature review

OBJECTIVE

Recently, psychological, and behavioral interventions such as cognitive functional therapy (CFT) has gained significant attention in musculoskeletal rehabilitation. We aimed to compare interventions with a CFT component in adults (>18 years old) suffering from chronic neck pain (CNP) or chronic whiplash associated disorders (>3 months) with another intervention or no intervention, in pain, disability, kinesiophobia, or any other reported outcome measure.

RESULTS

One case-study and three randomized controlled trials met the eligibility criteria. Statistically and clinically significant improvement in pain was found in favour of CFT combined with scapular exercise compared to exercise alone (MD = -19.91; 95%CI: -24.18 to -15.64) and controls (MD = -48.91; 95%CI: -53.88 to -43.94) at the very-short term follow-up. A significant difference in kinesiophobia was found at the short-term follow-up in favour of CFT and exercise compared to exercise alone (MD = -13.23; 95%CI-16.94 to -9.52) and controls (MD = -40.81 95%CI: -44.55 to -37.07). Finally, statistically and clinically significant improvement was found in favour of CFT compared to controls at the short-term follow-up in stress (MD = -36.62, 95%CI: 43.47 to -29.77), fear avoidance (MD = -35.44; 95%CI: 42.57 to -28.31), anxiety (MD = -34.43; 95%CI: 41.90 to -26.96), pain catastrophizing (MD = -25.19; 95%CI: 32.49 to -17.89), depression (MD = -30.72; 95%CI: 38.37 to -23.07), but a significant and clinically difference in favour of the control group at self-efficacy (MD = 29.56; 95%CI20.70 to 38.42).

CONCLUSIONS

Very low certainty evidence suggests that CFT alone or in combination with exercise may produce better outcomes than no treatment or exercise alone. The results should be interpreted with caution, given that the number of studies assessing CFT in CNP is limited.

The association between physical intervention use and treatment outcomes in patients participating in an online and psychologically informed pain management program

BACKGROUND

The availability of multidisciplinary care for the management of chronic pain is uncommon outside specialist clinics. The present study aims to determine the physical intervention use of patients participating in an online psychological pain management program and whether exposure to physical interventions in these patients alters treatment outcomes compared with patients who do not access physical interventions.

METHODS

Data were obtained from 2 previously published randomized controlled trials of an online psychological pain management program. Physical intervention exposure (categories: none, 1-3 sessions, 4+ sessions) was assessed at baseline, after treatment, and at 3-month follow-up. Primary outcomes included depression, anxiety, pain intensity, and pain-related disability. Generalized estimating equation models were used to compare treatment outcomes among those with different physical intervention frequencies and periods of exposure. We assessed whether changes in primary outcomes differed (moderated) by the period and category of physical intervention exposure.

RESULTS

Of the patients (n = 1074) who completed the baseline questionnaire across both randomized controlled trials, 470 (44%) reported physical intervention use at baseline, 383 (38%) reported physical intervention use after treatment, and 363 (42%) reported physical intervention use at 3-month follow-up. On average, there were moderate-large reductions from baseline to after treatment with respect to all outcomes (Cohen's d = 0.36-0.82). For all outcomes, the interaction of time by physical intervention exposure was statistically nonsignificant.

CONCLUSION

A substantial proportion of patients who participated in a psychologically informed pain management program were establishing, continuing, or stopping additional physical interventions. The frequency of and period of exposure to physical interventions did not appear to moderate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12613000252718 and ACTRN12615001003561). The website for registration information is https://www.anzctr.org.au.

The effect of cognitive functional therapy on the plantar pressure distribution symmetry in patients with chronic non-specific low back pain: A randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effect of Cognitive functional therapy (CFT) on plantar pressure distribution symmetry in chronic non-specific low back pain (CNSLBP) patients.

METHOD

forty females with NSCLBP (age range 30-50 years) were recruited for clinical trials. They were randomly divided into experimental and control groups (Each group had 20 patients). The patients in the experimental group received CFT for 8 weeks. The primary outcome was psychological variables inclusive of pain, kinesiophobia and disability. The secondary outcome was plantar pressure distribution symmetry which assessment in standing condition. The Covariance statistical method was used for data analysis.

RESULTS

The results of covariance analysis for primary outcome showed a significant difference (p < 0.05) with a reduction of 52 % in pain (p = 0.001), 12 % in kinesiophobia (p = 0.001) and 41% in disability (p = 0.001). Also, the results of covariance analysis for secondary outcome showed a significant difference in plantar pressure distribution symmetry of inter-limbs foot (p = 0.007), forward and backward in the right foot (p = 0.002) and forward and backward in the left foot (p = 0.001).

CONCLUSION

CFT reduces of pain, kinesiophobia and disability. In addition significant difference in the plantar pressure distribution symmetry was observed, which it is argued the plantar pressure asymmetric can be influenced by psychological factors.

A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial

Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients' perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of "The Journey to Self-Management." Within this overarching narrative, four distinct narratives were identified, beginning with "Left High and Dry," capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included "Plain, Smooth Sailing," describing a journey of relative ease and lack of obstacles; "Learning the Ropes and Gaining Sea Legs," capturing an iterative process of learning and negotiating setbacks; and "Sailing Through Headwinds," describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mitigating Persistent Symptoms Following Rehabilitation in Musculoskeletal Disorders: A Scoping Review on After-discharge Strategies

BACKGROUND

The majority of patients with musculoskeletal pain (62% to 64%) achieve their treatment goals upon completing rehabilitation. However, a high re-consultation rate after discharge is frequently reported. Numerous authors have recognized the necessity of secondary prevention programs (after-discharge strategy) to ensure that the gains are maintained or further pursued after the completion of a rehabilitation program. Little is known about the different strategies currently in use, and a detailed review of the existing strategies is needed for future integration into the healthcare systems.

OBJECTIVE

This review systematically scopes and synthesizes the after-discharge strategies reported in the literature following rehabilitation for individuals experiencing musculoskeletal pain.

METHODS

Four databases (OVID MEDLINE, EMBASE, Web of Sciences, and OVID PsycInfo) were screened from their inception until May 4, 2023. Literature search, screening, and extraction were performed according to the PRISMA extension for scoping review guidelines.

RESULTS

Different after-discharge strategies were identified and grouped into 2 main categories: (1) in-person and (2) remote strategies. In-person strategies included (1.1) in-person booster sessions and (1.2) the use of existing community programs after discharge. Remote strategies included remote strategies that (2.1) involve a health care professional service or (2.2) strategies that do not involve any health care professional service.

DISCUSSION

We identified various after-discharge strategies designed to sustain gains and improve patients' self-management skills following the completion of a rehabilitation program. The existence of numerous promising strategies suggests their potential suitability for various contexts.

Chronic Pain Management Approaches among Spanish Physiotherapists: Influences, Practices, Barriers, and Challenges

This study evaluated Spanish physiotherapists' orientations toward biopsychosocial and biomedical approaches in chronic pain management through a cross-sectional survey of 447 registered professionals. Validated questionnaires assessed knowledge, attitudes, and beliefs. Multivariate analysis of covariance (MANCOVA) identified influential factors and ordinal regression determined the frequency of biopsychosocial application. Content analysis of open-ended responses explored barriers to biopsychosocial implementation. Over 50% of physiotherapists favored the biopsychosocial model, influenced by interdisciplinary work settings, advanced pain knowledge, and specific training. Comprehensive pain knowledge significantly impacted both biomedical and biopsychosocial orientations inversely. The biomedical approach was more prevalent among those with lower education levels and less pain knowledge, particularly at the beginning or over 20 years into their careers. Despite the theoretical preference for biopsychosocial among Spanish physiotherapists, practical application was infrequent, with only 9.8% always using it and 40.7% frequently. Self-reported confidence and skills were crucial determinants of biopsychosocial implementation frequency. Significant barriers included inadequate psychological skills (63.6%), coordination challenges (47.6%), time constraints (43.6%), patient misconceptions (34.2%), and systemic issues. These findings align with international research, highlighting the need to bridge the gap between theoretical knowledge and clinical practice. Addressing these challenges through targeted training and systemic reforms is crucial for improving chronic pain management globally.

Unveiling relevant emotions, cognitions, and behaviours from the viewpoint of people with chronic low back pain: A qualitative study with patient involvement

OBJECTIVE

To gain insight into the emotions, cognitions, and behaviours experienced by people with chronic low back pain (CLBP) undergoing invasive treatment in a pain unit.

DESIGN

A cross-sectional qualitative study based on individual interviews. This study included patient involvement in its design and development.

METHODS

An interpretative phenomenological approach was adopted to understand the multidimensional experience of patients. The interview script was a translated, adapted, and expanded version of the one proposed by Cognitive and Functional Therapy. A mixed coding method was applied to structure the interviews. Three themes were created, with the three most frequently reported emotions, cognitions, and behaviours as subthemes. A patient with CLBP approved the initial protocol and the aim of the study. Subsequently, the patient contributed questions to the interview script, checked the coding process, and approved the final version of the manuscript.

RESULTS

Twenty-two patients undergoing epidural infiltrations in a pain unit were interviewed. (i)"Fears", (ii)"Frustration", and (iii)"Worry" were the three most commonly expressed emotions. Cognitions related to (i)"Pain predictability", (ii)"Pain description and perception", and (iii)"Pain interference/disability" were also widely reported. The theme "Behaviours" was composed of the following subthemes: (i)"Strategies for managing symptoms", (ii)"Social behaviours", and (iii)"Strategies for coping with daily tasks". Noteworthily, cognitions related to the (i)"Diagnosis", (ii)"Health system attention", and (iii)"Medical prescriptions" arose from questions provided by patient involvement.

CONCLUSION

Patients with CLBP expressed a wide variety of emotions, cognitions, and behaviours that must be considered by health professionals with the goal of providing the best patient-centred care.

Individualized Cognitive Functional Therapy Compared with Conservative Treatment for Patients with Chronic Neck Pain-Study Protocol for a Single Blind Pragmatic Randomized Controlled Trial

Chronic neck pain (CNP) is one of the most common musculoskeletal conditions, is considered the second leading cause of pain, and is among the leading causes of disability. Cognitive Functional Therapy (CFT) is a novel behavioral therapy for individualizing the management of spinal pain targeting the multidimensional aspect of musculoskeletal pain. This study outlines the protocol for an assessor-blind randomized controlled trial (RCT) designed to compare an individualized Cognitive Functional Therapy (CFT) intervention with usual care in terms of pain and disability. Aiming for a pragmatic intervention, the CFT group will receive 16 sessions based on patient's condition characteristics, and clinical presentation and progression. The control group will receive 16 sessions of standardized usual care (electrotherapy, massage, posture exercise, and educations). Both groups will have the same intervention duration. Patients will be randomly allocated into groups and will be assessed at baseline, at the 8th session, at the 16th session, and 3 months after randomization. Primary outcomes will be pain, disability, cervical range of motion, and neck muscle isometric strength. To our knowledge, this study will be the first RCT to compare the clinical effectiveness of CFT compared to UC for adults with CNP. The study results will provide information about the use of CFT in clinical practice.

Cognitive Functional Therapy compared with usual physiotherapy care in people with persistent low back pain: a mixed methods feasibility randomised controlled trial in the United Kingdom National Health Service

OBJECTIVES

To determine the feasibility of completing a definitive randomised controlled trial (RCT), evaluating the clinical and cost-effectiveness of Cognitive Functional Therapy (CFT) in comparison to usual physiotherapy care (UPC), for people with persistent low back pain (LBP).

DESIGN AND SETTING

A two-arm parallel feasibility RCT completed in a United Kingdom (UK) Secondary Care National Health Service (NHS) physiotherapy service.

PARTICIPANTS

Sixty adult participants who reported LBP lasting for more than three months, that was not attributable to a serious (e.g. cancer) or specific (e.g. radiculopathy) underlying cause, were invited to participate. Participants were allocated at random to receive CFT or UPC.

INTERVENTIONS

Cognitive Functional Therapy and Usual Physiotherapy Care for persistent LBP.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of completing a definitive RCT, defined by recruitment of at least 5 participants per month, delivery of CFT per protocol and securing relevant and acceptable outcome measures. Data concerning study processes, resources, management and participant reported outcome measures were collected at baseline, 3, 6 and 12-month follow-up.

RESULTS

Sixty participants (n = 30 CFT and n = 30 UPC) were recruited with 80% (n = 48), 72% (n = 43) and 53% (n = 32) retained at 3, 6 and 12-month follow-up respectively. NHS physiotherapists were trained to competence and delivered CFT with fidelity. CFT was tolerated by participants with no adverse events. Relevant and clinically important outcome data were collected at all time points (0.4%, 3%, 1% and 0.8% of data was missing from the returned outcome measure booklets at baseline and 3, 6 and 12-month follow-up respectively). The Roland-Morris disability questionnaire was considered the most suitable primary outcome measure with a proposed sample size of 540 participants for a definitive cluster RCT.

CONCLUSION

It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future study should incorporate an internal pilot to address aspects of feasibility further, including participant retention strategies.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN12965286 CONTRIBUTION OF THE PAPER.

Process of change for people with knee osteoarthritis undergoing cognitive functional therapy: a replicated single-case experimental design study

PURPOSE

To examine the applicability and process of change of Cognitive Functional Therapy (CFT) in the management of pain and disability in people with knee osteoarthritis who were offered knee replacement surgery and had risk factors for poor response to surgery.

METHODS

Single-case experimental design with a mixed-methods, repeated measures approach was used to investigate the process of change through CFT in four participants. Qualitative interviews investigated beliefs, behaviours and coping responses, and self-reported measures assessed pain, disability, psychological factors, and function at 25 timepoints. Study registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619001491156).

RESULTS

Qualitative data indicate that CFT promoted helpful changes in all participants, with two responses observed. One reflected a clear shift to a biopsychosocial conceptualisation of osteoarthritis, behavioural re-engagement and the view that a knee replacement was no longer necessary. The other response reflected a mixed conceptualisation with dissonant beliefs about osteoarthritis and its management. Psychological and social factors were identified as potential treatment barriers. Overall, quantitative measures supported the qualitative findings.

CONCLUSION

The process of change varies between and within individuals over time. Psychological and social barriers to treatment have implications for future intervention studies for the management of knee osteoarthritis.IMPLICATIONS FOR REHABILITATIONCognitive Functional Therapy is applicable in the management of knee osteoarthritis.Reconceptualisation of osteoarthritis reflected a helpful change.Psychological and social factors emerged as barriers to recovery.

Long-term impact of self-compassion training with core stability exercise on patients with nonspecific chronic low back pain: A randomized controlled trial

OBJECTIVE

To compare the long-term effectiveness of self-compassion therapy (SCT) combined with core stability exercise (CSE) versus CSE alone in managing nonspecific chronic low back pain (NCLBP).

METHODS

The combined group received SCT and CSE, while the exercise group only received CSE. Treatment was administered once weekly for four weeks, followed by one year of follow-up. The primary outcomes were changes in functional limitations (measured by Roland and Morris Disability Questionnaire scores[RMDQ]) and self-reported back pain (measured by the Numeric Pain Rating Scale[NRS]) at 52 weeks, with assessments also conducted at 2, 4, and 16 weeks.

RESULTS

52 (83.9%) completed the follow-up assessments and were included in the analysis (42 women [80.8%]; mean [SD] age,35.3 [10.0] years). In the combined group, the baseline mean (SD) RMDQ score was 9.3 (4.1),5.7 (5.8) at 2 weeks, 3.8 (3.4) at 4 weeks, 3.8 (3.7) at 16 weeks, and 2.4 (2.7) at 52 weeks. For the exercise group, the RMDQ scores were 8.2 (3.3) at baseline, 6.2 (4.2) at 2 weeks, 5.5 (4.7) at 4 weeks, 4.4 (4.5) at 16 weeks, and 5.2 (5.6) at 52 weeks. The estimated mean difference between the groups at 52 weeks was -3.356 points (95% CI, -5.835 to -0.878; P = 0.009), favoring the combined group. NRS scores showed similar changes.

CONCLUSION

The addition of self-compassion therapy enhances the long-term efficacy of core stability training for NCLBP (Preregistered at chictr.org.cn:ChiCTR2100042810).

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

BACKGROUND

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

AIM

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

DESIGN

Cross-sectional survey.

SETTING

Nine hospitals in Jiangsu Province, China.

POPULATION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL REHABILITATION IMPACT

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

Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis

Chronic low back pain (cLBP) is a major cause of disability and healthcare expenditure worldwide. Its prevalence is increasing globally from somatic and psychosocial factors. While non-pharmacological management, and in particular physiotherapy, has been recommended as a first-line treatment for cLBP, it is not clear what type of physiotherapeutic approach is the most effective in terms of pain reduction and function improvement. This analysis is rendered more difficult by the vast number of available therapies and a lack of a widely accepted classification that can effectively highlight the differences in the outcomes of different management options. This study was conducted according to the PRISMA guidelines. In January 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All the randomised controlled trials (RCTs) which compared the efficacy of physiotherapy programs in patients with cLBP were accessed. Studies reporting on non-specific or mechanical cLPB were included. Data concerning the Visual Analogic Scale (VAS) or numeric rating scale (NRS), Roland Morris Disability Questionnaire (RMQ) and Oswestry Disability Index (ODI). Data from 12,773 patients were collected. The mean symptom duration was 61.2 ± 51.0 months and the mean follow-up was 4.3 ± 5.9 months. The mean age was 44.5 ± 9.4 years. The mean BMI was 25.8 ± 2.9 kg/m2. The Adapted Physical Exercise group evidenced the lowest pain score, followed by Multidisciplinary and Adapted Training Exercise/Complementary Medicine. The Adapted Physical Exercise group evidenced the lowest RMQ score followed by Therapeutic Exercises and Multidisciplinary. The Multidisciplinary group evidenced the lowest ODI score, followed by Adapted Physical Exercise and Physical Agent modalities. Within the considered physiotherapeutic and non-conventional approaches to manage nonspecific and/or mechanic cLBP, adapted physical exercise, physical agent modalities, and a multidisciplinary approach might represent the most effective strategy to reduce pain and disability.

Quantifying lumbar sagittal plane kinematics using a wrist-worn inertial measurement unit

Wearable sensors like inertial measurement units (IMUs), and those available as smartphone or smartwatch applications, are increasingly used to quantify lumbar mobility. Currently, wearable sensors have to be placed on the back to measure lumbar mobility, meaning it cannot be used in unsupervised environments. This study aims to compare lumbar sagittal plane angles quantified from a wrist-worn against that of a lumbar-worn sensor. Twenty healthy participants were recruited. An IMU was placed on the right wrist and the L3 spinal level. Participants had to position their right forearm on their abdomen, parallel to the floor. Three sets of three consecutive repetitions of flexion, and extension were formed. Linear mixed models were performed to quantify the effect of region (lumbar vs. wrist) on six outcomes [minimum, maximum, range of motion (ROM) of flexion and extension]. Only flexion ROM was significantly different between the wrist and lumbar sensors, with a mean of 4.54° (95% CI = 1.82°-7.27°). Across all outcomes, the maximal difference between a wrist-worn and lumbar-worn sensor was <8°. A wrist-worn IMU sensor could be used to measure gross lumbar sagittal plane mobility in place of a lumbar-worn IMU. This may be useful for remote monitoring during rehabilitation.

BACK-to-MOVE: Machine learning and computer vision model automating clinical classification of non-specific low back pain for personalised management

BACKGROUND

Low back pain (LBP) is a major global disability contributor with profound health and socio-economic implications. The predominant form is non-specific LBP (NSLBP), lacking treatable pathology. Active physical interventions tailored to individual needs and capabilities are crucial for its management. However, the intricate nature of NSLBP and complexity of clinical classification systems necessitating extensive clinical training, hinder customised treatment access. Recent advancements in machine learning and computer vision demonstrate promise in characterising NSLBP altered movement patters through wearable sensors and optical motion capture. This study aimed to develop and evaluate a machine learning model (i.e., 'BACK-to-MOVE') for NSLBP classification trained with expert clinical classification, spinal motion data from a standard video alongside patient-reported outcome measures (PROMs).

METHODS

Synchronised video and three-dimensional (3D) motion data was collected during forward spinal flexion from 83 NSLBP patients. Two physiotherapists independently classified them as motor control impairment (MCI) or movement impairment (MI), with conflicts resolved by a third expert. The Convolutional Neural Networks (CNNs) architecture, HigherHRNet, was chosen for effective pose estimation from video data. The model was validated against 3D motion data (subset of 62) and trained on the freely available MS-COCO dataset for feature extraction. The Back-to-Move classifier underwent fine-tuning through feed-forward neural networks using labelled examples from the training dataset. Evaluation utilised 5-fold cross-validation to assess accuracy, specificity, sensitivity, and F1 measure.

RESULTS

Pose estimation's Mean Square Error of 0.35 degrees against 3D motion data demonstrated strong criterion validity. Back-to-Move proficiently differentiated MI and MCI classes, yielding 93.98% accuracy, 96.49% sensitivity (MI detection), 88.46% specificity (MCI detection), and an F1 measure of .957. Incorporating PROMs curtailed classifier performance (accuracy: 68.67%, sensitivity: 91.23%, specificity: 18.52%, F1: .800).

CONCLUSION

This study is the first to demonstrate automated clinical classification of NSLBP using computer vision and machine learning with standard video data, achieving accuracy comparable to expert consensus. Automated classification of NSLBP based on altered movement patters video-recorded during routine clinical examination could expedite personalised NSLBP rehabilitation management, circumventing existing healthcare constraints. This advancement holds significant promise for patients and healthcare services alike.

A Mind-Body Intervention to Improve Physical Activity for Patients with Chronic Hip-Related Pain: Protocol for a Mixed Methods Study

BACKGROUND

Pain and dysfunction persist for most patients following hip-related pain treatment. Additionally, individuals with hip-related pain are typically less physically active than individuals without hip pain, despite evidence that regular physical activity reduces chronic musculoskeletal pain. Poor psychological health is common in patients with hip-related pain and further reinforces low physical activity. Mind-body interventions can improve psychological health and activity levels but have yet to be integrated to provide comprehensive, psychologically informed care for patients with hip-related pain. Thus, we are using the NCCIH intervention development framework to develop Helping Improve PSychological Health (HIPS), a novel, multimodal mind-body intervention to improve physical activity for individuals with hip-related pain and poor psychological health.

METHODS

We will recruit physical therapists (N = 20) and patients with hip-related pain (N = 20) to participate in 60 min qualitative interviews (focus groups with therapists; one-on-one interviews with patients). Using these data, we will develop the initial HIPS intervention and provider training materials. One physical therapist will be trained to deliver the HIPS intervention to five participants in an open pilot trial. Participants will attend six 30 min HIPS intervention sessions. We will collect quantitative data on satisfaction, improvement, and physical activity, alongside qualitative exit interviews with participants and the physical therapist in order to refine the HIPS intervention and provider training materials.

RESULTS

This study has been approved by the MGB IRB. We aim to develop and test the initial feasibility of the HIPS intervention in an open pilot trial. The findings from this project will inform a subsequent feasibility RCT.

Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review

BACKGROUND

Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point.

METHODS

In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used.

RESULTS

Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001).

CONCLUSION

Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ.

LEVEL OF EVIDENCE

I systematic review of RCTs.

Effects of Pain Neuroscience Education and Physiotherapy on Chronic Low Back Pain, Fear of Movement and Functional Status: A Randomised Pilot Study

Background: Chronic non-specific low back pain is a non-harmous condition often found in the general population. It is one of the most significant disabilities and needs different treatment modalities. This study investigates the effects of pain neuroscience education and physiotherapy on pain intensity, fear of movement and functional status in a Lithuanian cohort with non-specific low back pain. Methods: The study was performed at the primary health care unit in Kaunas, Lithuania. The key inclusion criterion was persistent non-specific low back pain longer than three months and which affects daily life functions. Thirty participants (mean 33.47, SD 4.38 years age, 70% women) were randomised into two training groups with and without pain neuroscience education (for a total of 60 min of teaching). Physiotherapy was performed twice per week during 45 min/session for a period of 10 weeks with exercises which strengthen, stabilize, and stretch the spinal cord muscles. Outcomes included pain intensity, kinesiophobia and disability and these were measured by self-scored questionnaires (numeric rating scale, Tampa scale for kinesiophobia-11, Oswestry disability index and the Roland-Morris questionnaire, respectively). Results: The results indicate that both groups improved in the measured outcomes, with the only difference between them being a better improvement in kinesiophobia in the group receiving physiotherapy and pain neuroscience education. Conclusions: The results of this study confirm that a relatively short intervention of pain neuroscience education enhances the effects of physiotherapy and should be implemented in clinical practice.