The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting

Trunk postural control during unstable sitting among individuals with and without low back pain: A systematic review with an individual participant data meta-analysis

INTRODUCTION

Sitting on an unstable surface is a common paradigm to investigate trunk postural control among individuals with low back pain (LBP), by minimizing the influence lower extremities on balance control. Outcomes of many small studies are inconsistent (e.g., some find differences between groups while others do not), potentially due to confounding factors such as age, sex, body mass index [BMI], or clinical presentations. We conducted a systematic review with an individual participant data (IPD) meta-analysis to investigate whether trunk postural control differs between those with and without LBP, and whether the difference between groups is impacted by vision and potential confounding factors.

METHODS

We completed this review according to PRISMA-IPD guidelines. The literature was screened (up to 7th September 2023) from five electronic databases: MEDLINE, CINAHL, Embase, Scopus, and Web of Science Core Collection. Outcome measures were extracted that describe unstable seat movements, specifically centre of pressure or seat angle. Our main analyses included: 1) a two-stage IPD meta-analysis to assess the difference between groups and their interaction with age, sex, BMI, and vision on trunk postural control; 2) and a two-stage IPD meta-regression to determine the effects of LBP clinical features (pain intensity, disability, pain catastrophizing, and fear-avoidance beliefs) on trunk postural control.

RESULTS

Forty studies (1,821 participants) were included for the descriptive analysis and 24 studies (1,050 participants) were included for the IPD analysis. IPD meta-analyses revealed three main findings: (a) trunk postural control was worse (higher root mean square displacement [RMSdispl], range, and long-term diffusion; lower mean power frequency) among individuals with than without LBP; (b) trunk postural control deteriorated more (higher RMSdispl, short- and long-term diffusion) among individuals with than without LBP when vision was removed; and (c) older age and higher BMI had greater adverse impacts on trunk postural control (higher short-term diffusion; longer time and distance coordinates of the critical point) among individuals with than without LBP. IPD meta-regressions indicated no associations between the limited LBP clinical features that could be considered and trunk postural control.

CONCLUSION

Trunk postural control appears to be inferior among individuals with LBP, which was indicated by increased seat movements and some evidence of trunk stiffening. These findings are likely explained by delayed or less accurate corrective responses.

SYSTEMATIC REVIEW REGISTRATION

This review has been registered in PROSPERO (registration number: CRD42021124658).

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Postural control of the trunk in individuals with and without low back pain during unstable sitting: A protocol for a systematic review with an individual participant data meta-analysis

Introduction

Postural control of the trunk is critical for performance of everyday activities and the health of spinal tissues. Although some studies report that individuals with low back pain (LBP) have poorer/compromised postural control than pain-free individuals when sitting on an unstable surface, others do not. Analyses commonly lack the statistical power to evaluate the relevance of features that could impact the performance of postural control, such as sex, age, anthropometrics, pain intensity or disability. This paper outlines a protocol for a systematic review with an individual participant data (IPD) meta-analysis that aims to synthesise the evidence and evaluate differences of postural control measures between individuals with and without LBP during unstable sitting.

Methods and analysis

A systematic review with IPD meta-analysis will be conducted according to PRISMA-IPD guidelines. To identify relevant studies, electronic databases and the reference lists of included articles will be screened. Unstable seat movements are derived from centre of pressure (CoP) data using a force plate or angle of the seat using motion systems/sensors. The comprehensiveness of reporting and methodological quality of included studies will be assessed. Analysis will involve a descriptive analysis to synthesise the findings of all included studies and a quantitative synthesis using two-stage IPD meta-analysis of studies that include both individuals with and without LBP for which IPD set can be obtained from authors. Analyses will include consideration of confounding variables.

Ethics

Exemption from ethical approval was obtained for this review (University of Queensland, ID: 2019003026).

Systematic review registration

PROSPERO ID: CRD42021124658.

The Determination of the Efficacy of Neural Therapy in Conservative Treatment-resistant Patients with Chronic Low Back Pain

STUDY DESIGN

A randomized clinical trial.

OBJECTIVE

The aim of this article is to determine the effectiveness of neural therapy (NT) in patients with chronic low back pain (LBP) who are resistant to medical and physical therapies.

SUMMARY OF BACKGROUND DATA

Patients with LBP generally respond well to the treatment, whereas some cases do not improve via medical and physical therapies. Although trigger point injections (TPIs) may be an effective short-term treatment in selected patients with LBP, they are not recommended in patients with chronic LBP due to a long-lasting benefit not being demonstrated.

METHODS

Fifty patients, who had inadequate functional recovery and pain relief, with chronic LBP were randomly divided into two groups: Group 1, only single TPI; Group 2, NT. NT including local-segmental treatment (intradermal injections) on the lumbosacral region, 5 M injection (intradermal injections of the projection of the pelvic organs on the suprapubic region), pelvic plexus injection, i.v. injection (2 mL) for five sessions per a week. All patients in group 2 received the same kind of intervention every seance but interference field injections (injections into umbilicus for all patients and injections into scars resulting from vaccination and surgical operations such as cesarean section, if any) were also applied at the only first seance. The Visual Analog Scale (VAS) scores for current pain during activities and Roland Morris Disability Questionnaire (RMDQ) scores for disability were recorded at baseline and 1, 3, 6 months post-injection.

RESULTS

The VAS and RMDQ scores at 3 and 6 months were significantly lower in Group 2 versus Group 1 (P < 0.05).

CONCLUSION

NT may be an alternative treatment option in patients with chronic LBP for pain relief and functional recovery in the long run.Level of Evidence: 2.

The Long-Term Prognosis in People With Recent Onset Low Back Pain From Emergency Departments: An Inception Cohort Study

Most studies investigating the course of recent-onset low back pain (LBP) included patients from primary care. We aimed to describe the prognosis in people with recent-onset LBP presenting to emergency departments (EDs) and to identify prognostic factors for nonrecovery. This inception cohort study with a 1-year follow-up recruited 600 consecutive acute LBP patients presenting to 4 EDs. The outcomes measured the days to recover from pain, recover from disability, return to previous work hours and duties, and complete recovery. Within 12 months, 73% of participants (95% confidence interval [CI] = 69-77) recovered from pain, 86% (95% CI = 82-90) recovered from disability, 79% (95% CI = 71-87) returned to previous work hours and duties, and 70% (95% CI = 66-74) completely recovered. The median recovery times were 67 days (95% CI = 54-80) to recover from pain, 37 days (95% CI = 31-43) to recover from disability, 37 days (95% CI = 25-49) to return to previous work hours and duties, and 70 days (95% CI = 57-83) to recover completely. Higher pain levels, a higher perceived risk of persistent LBP, more days of reduced activity due to LBP, more pain sites, and higher duration of LBP were associated with complete nonrecovery within 6 months. PERSPECTIVE: This information relates to prognosis and to likely recovery times for patients with recent-onset LBP in EDs. The findings also confirm previous factors associated with poor outcomes in patients with recent-onset LBP.

Prognostic factors for pain chronicity in low back pain: a systematic review

Supplemental Digital Content is Available in the Text.

Several prognostic factors are related to low back pain chronicity, and these should be taken into account when planning more comprehensive models in its prevention.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.

The effects of shoes and insoles for low back pain: a systematic review and meta-analysis of randomized controlled trials

The aim of this review was to examine the effects of shoes and insoles on low back pain (LBP). Seven electronic databases were searched from their inception to May 2020. The methodological quality of the 14 included studies was assessed by PEDro scale. Quality of evidence was assessed using GRADE. Moderate evidence on the disability questionnaire score (SMD, 0.52; 95% CI, 0.28 to 0.77; P < 0.001) and pain score (SMD, 0.61; 95% CI, 0.36 to 0.85; P < 0.001) of the custom-made orthotics for chronic LBP compared with no orthotics/insoles intervention was found. Meta-analysis results also showed moderate evidence on the disability questionnaire score (SMD, 0.44; 95% CI, 0.05 to 0.82; P =0.03) in patients who wore unstable shoes compared with regular shoes. Pain and life quality scores showed low-quality evidence of unstable shoes for chronic LBP. Custom-made orthotics and unstable shoes can be recommended to patients as a management option of chronic LBP.

Defining pain and interference recovery trajectories after acute non-catastrophic musculoskeletal trauma through growth mixture modeling

BACKGROUND

Recovery trajectories support early identification of delayed recovery and can inform personalized management or phenotyping of risk profiles in patients. The objective of this study was to investigate the trajectories in pain severity and functional interference following non-catastrophic musculoskeletal (MSK) trauma in an international, mixed injury sample.

METHODS

A prospective longitudinal cohort (n = 241) was formed from patients identified within four weeks of trauma, from attendance at emergency or urgent care centres located in London, ON, Canada, or Chicago, IL, USA. Pain interference was measured via the Brief Pain Inventory (London cohort) or the Neck Disability Index (Chicago cohort). Pain severity was captured in both cohorts using the numeric pain rating scale. Growth mixture modeling and RM repeated measures ANOVA approaches identified distinct trajectories of recovery within pain interference and pain severity data.

RESULTS

For pain interference, the three trajectories were labeled accordingly: Class 1 = Rapid recovery (lowest intercept, full or near full recovery by 3 months, 32.0% of the sample); Class 2 = Delayed recovery (higher intercept, recovery by 12 months, 26.7% of the sample); Class 3 = Minimal or no recovery (higher intercept, persistently high interference scores at 12 months, 41.3% of the sample). For pain severity, the two trajectories were labeled: Class 1 = Rapid recovery (lower intercept, recovery by 3 months, 81.3% of the sample); and Class 2 = Minimal or no recovery (higher intercept, flat curve, 18.7% of the sample). The "Minimal or No Recovery" trajectory could be predicted by female sex and axial (vs. peripheral) region of trauma with 74.3% accuracy across the 3 classes for the % Interference outcome. For the Pain Severity outcome, only region (axial trauma, 81.3% accuracy) predicted the "Minimal or No Recovery" trajectory.

CONCLUSIONS

These results suggest that three meaningful recovery trajectories can be identified in an international, mixed-injury sample when pain interference is the outcome, and two recovery trajectories emerge when pain severity is the outcome. Females in the sample or people who suffered axial injuries (head, neck, or low back) were more likely to be classed in poor outcome trajectories.

TRIAL REGISTRATION

National Institutes of Health - clinicaltrials.gov ( NCT02711085 ; Retrospectively registered Mar 17, 2016).

Assessment of Lumbar Lordosis Distribution with a Novel Mathematical Approach and Its Adaptation for Lumbar Intervertebral Disc Degeneration

Introduction

Low back pain and disc degeneration could be linked to global spinal geometry. Our study aimed to develop a reliable new mathematical method to assess the local distribution of total lumbar lordosis with a single numeric parameter and compare it with lumbar intervertebral disc degeneration using routine MRI scans.

Methods

An online, open access, easy-to-use platform for measurements was developed based on a novel mathematical approach using MRIs of 60 patients. Our Spinalyze Software can be used online with uploaded MRIs. Several new parameters were introduced and assessed to describe variation in segmental lordosis distribution with a single numerical value. The Pfirrmann grading system was used for the classification of lumbar intervertebral disc degeneration. Relationships were investigated between the grade categories of L1-S1 lumbar discs and the MRI morphological parameters with correlation analysis.

Results

Results confirm that the determination of measurement points and calculated parameters are reliable (ICCs and Pearson r values > 0.90), and these parameters were independent of gender. The digression percentage (K%), one of our new parameters, did not show a statistical relationship with the Cobb-angle. According to our results, the maximum deflection breaking-point of lumbar lordosis and its location can be different with the same Cobb-angle and the distribution of global lordosis is uneven because the shape of the lumbar lordosis is shifted downward and centered around the L4 lumbar vertebra. The interobserver reliability of the Pfirrmann grades reading was in the excellent agreement category (88.33% agreement percentage, 0.84 kappa), and digression percentage (K%) showed a significant negative correlation with all L1-S1 disc grades with increasing r correlation values. This means that the smaller the value of digression percentage (K%), the more the number of worn discs in the lower lumbar sections.

Conclusions

Spinalyze Software based on a novel mathematical approach provides a free, easy-to-use, reliable, and online measurement tool using standard MRIs to approximate the curvature of lumbar lordosis. The new reliable K% (digression percentage) is one single quantitative parameter to assess the local distribution of total lumbar lordosis. The results indicate that digression percentage (K%) may possibly be associated with the development of lumbar intervertebral disc degeneration. Further evaluation is needed to assess its behavior and advantage.

Framework for improving outcome prediction for acute to chronic low back pain transitions

Clinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.

Predictive factors of high societal costs among chronic low back pain patients

Background

Societal costs of low back pain (LBP) are high, yet few studies have been performed to identify the predictive factors of high societal costs among chronic LBP patients. This study aimed to determine which factors predict high societal costs in patients with chronic LBP.

Methods

Data of 6,316 chronic LBP patients were used. In the main analysis, high societal costs were defined as patients in the top 10% of cost outcomes. Sensitivity analyses were conducted using patients in the top 5% and top 20% of societal costs. Potential predictive factors included patient expectations, demographic factors (e.g. age, gender, nationality), socio‐economic factors (e.g. employment, education level) and health‐related factors (e.g. body mass index [BMI], general health, mental health). The final prediction models were obtained using backward selection. The model's prognostic accuracy (Hosmer–Lemeshow X², Nagelkerke's R²) and discriminative ability (area under the receiver operating curve [AUC]) were assessed, and the models were internally validated using bootstrapping.

Results

Poor physical health, high functional disability, low health‐related quality of life, high impact of pain experience, non‐Dutch nationality and decreasing pain were found to be predictive of high societal costs in all models, and were therefore considered robust. After internal validation, the models' fit was good, their explained variance was relatively low (≤14.1%) and their AUCs could be interpreted as moderate (≥0.71).

Conclusion

Future studies should focus on understanding the mechanisms associated with the identified predictors for high societal costs in order to design effective cost reduction initiatives.

Significance

Identifying low back pain patients who are at risk (risk stratification) of becoming high‐cost users and making appropriate initiatives could help in reducing high costs.

Characteristics of Locomotive Syndrome in Japanese Patients with Chronic Pain and Results of a Path Analysis Confirming the Relevance of a Vicious Cycle Involving Locomotive Syndrome, Musculoskeletal Pain, and Its Psychological Factors

Introduction:

The current aging population has a major impact on public health. Locomotive syndrome (LS) is a condition that carries a high risk for developing systemic musculoskeletal disability.

Methods:

Participants were patients with chronic pain (n = 415) who were examined at the Japanese multidisciplinary pain centers of the research consortium. They completed the 25-question geriatric locomotive function scale (GLFS-25; LS screening tool), an 11-point numerical rating scale (NRS) of pain intensity and its psychological distresses, health-related quality of life (HRQOL) questionnaire, and a survey of exercise habits. A multifaceted analysis of the relevance of the pain, psychological distresses, and LS were conducted using SPSS and AMOS software.

Results:

337 patients (81.2%) were found to have LS. The final model of a multifaceted analysis demonstrated good fitness for the “vicious cycle” model among the results of LS, pain intensity, impairment of self-efficacy, and depression; these parameters independently impaired HRQOL. Anxiety related to falling (GLFS-25) and exercise habits affected the model.

Conclusions:

These findings indicate LS, LS-related pain, and psychological distress create a vicious cycle, resulting in the impairment of HRQOL. Treatment strategies for LS should inclusively focus on musculoskeletal disorders, pain, and pain-related psychological factors.

Criteria for inclusion in programs of functional restoration for chronic low back pain: Pragmatic Study

BACKGROUND

Individuals with chronic low back pain (cLBP) may benefit from multimodal functional restoration programs (FRPs).

OBJECTIVE

The aim of this study was to analyze characteristics of individuals with cLBP who were referred or not to an FRP. Because cLBP is a bio-psycho-social disorder, medical and social parameters were analysed.

METHODS

This was an observational cross-sectional study performed in 2017 in 6 tertiary centres in France. Consecutive individuals with cLBP visiting a rheumatologist or physical medicine and rehabilitation physician were included. Individuals referred or not to an FRP were compared by demographic characteristics, duration of sick leave over the past year, self-reported physical activity>1h/week, pain (numeric rating scale 0-10), anxiety/depression (Hospital Anxiety and Depression Scale), disability (Oswestry Disability Index) and kinesiophobia (Tampa Kinesiophobia Scale). Univariate and multivariate logistic regression analyses were performed, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 147 individuals with cLBP. The mean (SD) age was 49 (12) years and 88 (60%) were women; 58 (38%) were referred to an FRP. On multivariate analysis, referral to an FRP was associated with reduced pain level (OR: 0.95, 95% CI: 0.91-0.99, for each 1-point increase in pain score), self-reported lack of physical activity (OR: 0.84, 95% CI: 0.72-0.98) and longer sick leave (OR: 1.03, 95% CI: 1.01-1.05, for 30 more days of sick leave).

CONCLUSION

In this multicentric observational study, referral to an FRP was linked to pain, self-reported physical activity and sick leave but not medical characteristics assessed. These findings confirm the bio-psycho-social approach of FRPs for cLBP.

Highly Cited Works in Spinal Disorders: The Top 100 Most Cited Papers Published in Spine Journals

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

To identify, and summarize the key findings of, the top 100 most highly cited works published in spinal disorder topic-specific journals.

SUMMARY OF BACKGROUND DATA

There is an abundance of published articles pertaining to spine surgery and spinal disorders. The number of citations a work receives provides a useful measure of its scientific impact. An understanding of the most cited works in spine surgery can identify literature that surgeons and researchers should be familiar with, point to the most active areas of research, inform the design of educational curricula, and help guide future research efforts.

METHODS

Journals relating to spinal disorders were identified using the Journal Citation Reports database. We then searched the Web of Science database for articles appearing in each of these journals. The top 100 most cited works were selected for analysis.

RESULTS

The top 100 most cited articles appeared in seven of eight journals dedicated to spinal disorders, with 84 in Spine and seven in the European Spine Journal. The citation count for individual articles ranged from 343 to 1949. Most works (73) were published between 1990 and 2004. The greatest number of articles (22) focused on low back pain, followed by biomechanics (13), degenerative disc disease (12), and lumbar spinal stenosis/lumbar fusion (9). With regard to study design, laboratory investigations were the most common (12), followed by guideline documents (11), reviews (10), and retrospective cohort studies (10).

CONCLUSION

The most cited works in spinal disorder journals are guidelines for low back pain, descriptions of quality of life (QOL) metrics, or laboratory investigations into spinal biomechanics. A gap exists for work relating to neck pain or cervical spinal pathology (e.g., cervical myelopathy), representing opportunity for future work. Time of publication, topic of study, study design, and journal are possible determinants of likelihood of citation.

LEVEL OF EVIDENCE

N/A.

The Effects of Pain Severity, Pain Catastrophizing, Depression, and Exercise on Perceived Disability in Acute Low Back Pain Patients

Background/Purpose: The effectiveness of cognitive treatments for low back pain, a prevalent and costly condition, are commonly based on the principles of the Cognitive Behavioral Model of Fear of Movement/(Re)injury. In this model, persons with a painful injury/experience who also engage in pain catastrophizing are most likely to avoid activity leading to disability. The validation of this model in patients with acute low back is limited. The purpose of this project was to examine the relationship of perceived disability with variables identified in the Cognitive Behavioral Model of Fear of Movement/(Re)injury such as, pain severity, pain catastrophizing, depression, and exercise in persons with acute low back pain. Methods: A multiple linear regression model was used to assess the association of perceived disability with pain severity, pain catastrophizing, depression, and exercise at baseline among subjects with acute low back pain (N = 44) participating in a randomized clinical trial to prevent transition to chronic low back pain. Results: Controlling for age, the overall model was significant for perceived disability (F[5, 35] = 14.2; p < .001). Higher scores of pain catastrophizing (p = .003) and pain severity (p < .001) were associated with higher perceived disability levels. Exercise and depression were not significantly associated with perceived disability. Implications: The use of the Cognitive Behavioral Model of Fear of Movement/(Re)injury in acute LBP patients is appropriate; because this model is commonly used as rationale for the effectiveness of cognitive treatments, these findings have clinical relevance in the treatment of this condition.

A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: Study protocol for The RELIEF Study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for seeking medical care. Manipulative therapies are a common treatment for LBP. Few studies have compared the effectiveness of different types of manipulative therapies. Moreover, the physiologic mechanisms underlying these treatments are not fully understood. Herein, we present the study protocol for The Researching the Effectiveness of Lumbar Interventions for Enhancing Function Study (The RELIEF Study).

METHODS AND STUDY DESIGN

The RELIEF Study is a Phase II RCT with a nested mechanistic design. It is a single-blinded, sham-controlled study to test the mechanisms and effectiveness of two manual therapy techniques applied to individuals (n = 162; 18-45 years of age) with chronic LBP. The clinical outcome data from the mechanistic component will be pooled across experiments to permit an exploratory Phase II RCT investigating the effectiveness. Participants will be randomized into one of three separate experiments that constitute the mechanistic component to determine the muscular, spinal, and cortical effects of manual therapies. Within each of these experimental groups study participants will be randomly assigned to one of the three treatment arms: 1) spinal manipulation, 2) spinal mobilization, or 3) sham laser therapy. Treatments will be delivered twice per week for 3-weeks.

DISCUSSION

This data from this will shed light on the mechanisms underlying popular treatments for LBP. Additionally, the coupling of this basic science work in the context of a clinical trial will also permit examination of the clinical efficacy of two different types of manipulative therapies.

Association between pain drawing and psychological factors in musculoskeletal chronic pain: A systematic review

BACKGROUND

It has been speculated that there is an association between pain area and psychological factors in chronic musculoskeletal pain conditions; however, this relation is not well established.

PURPOSE

To investigate the association between pain distribution and psychological factors in chronic musculoskeletal pain conditions.

STUDY DESIGN

Systematic review.

METHODS

We searched the following databases using optimized search strategies: MEDLINE, PsycINFO, Scopus, Web of Science and Cochrane. Studies were included if they investigated the relation between pain area using a pain drawing (PD) and psychological factors measured by any consistent available method.

RESULTS

Eleven articles were included. A total of 1301 participants with different musculoskeletal pain conditions, including low back pain, whiplash-associated disorders and fibromyalgia took part in the studies. In three studies, the correlation between pain area and depression was weak (r = 0.15, p = N/A; r = 0.26, p < 0.05; r = 0.25, p = 0.01). Depression seemed to be a risk factor for pain in more body areas in one study (relative risk = 6.09, 95% CI = 1.1-33.5; p < 0.05). The relation between pain area and other psychological factors such as anxiety, kinesiophobia, catastrophizing, memory disturbances and concentration difficulties was also reported.

CONCLUSIONS

A definitive answer on the relation of psychological factors and pain area is not available; the findings suggest that only depression might have a weak relation with pain area. Future studies that investigate sensory, psychological, emotional, cognitive and behavioral aspects, and also more accurate methods of PD assessment, are needed.

Trajectories of Fear-Avoidance Beliefs on Physical Activity Over Two Years in People With Rheumatoid Arthritis

Objective

To identify and describe 2‐year trajectories of fear‐avoidance beliefs on physical activity and to identify predictors of these trajectories in people with rheumatoid arthritis (RA).

Methods

We included 2,569 persons with RA (77% women, mean age 58 years). Data on fear‐avoidance beliefs (Fear‐Avoidance Beliefs Questionnaire physical activity subscale [FABQ‐PA]; range 0–24), sociodemographics, disease‐related variables, self‐efficacy, and health‐enhancing physical activity (HEPA) were collected from registers and by questionnaires at baseline, 14, and 26 months. K‐means cluster analysis was used to identify fear‐avoidance trajectories, and multinomial logistic regression was used to identify predictors of trajectory membership.

Results

Three trajectories of fear‐avoidance beliefs were identified: low (n = 1,060, mean FABQ‐PA = 3), moderate (n = 1,043, mean FABQ‐PA = 9), and high (n = 466, mean FABQ‐PA = 15). Consistent predictors of being in the high fear‐avoidance trajectory versus the other 2 trajectories were high activity limitation, male sex, income below average, not performing current HEPA, and elevated anxiety/depression. In addition, less consistent predictors such as shorter education, more pain, and low exercise self‐efficacy were also identified.

Conclusion

Stable trajectories of fear‐avoidance beliefs on physical activity exist among people with RA. Fear‐avoidance may be targeted more effectively by tailoring physical activity promotion to vulnerable socioeconomic groups, men, and those with high activity limitation and anxiety/depression.

Abnormal Pain Response After a Compensable Shoulder Injury

Background:

The role of psychosocial factors has been established in patients with shoulder abnormalities. However, the prevalence of exaggerated pain behaviors and their association with the characteristics of injured workers have not been well studied.

Purpose:

To examine the prevalence of abnormal pain responses (APRs) in workers with active workers’ compensation claims for a shoulder injury and to examine the differences between workers with APRs versus workers without APRs.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

An analysis of electronic data files of injured workers was completed. An APR was defined as an exaggerated pain response during a clinical examination, including facial grimacing, shaking, withdrawal, nonanatomic dermatome or myotome disturbances, increased tenderness, regional symptoms, and verbal utterances such as groaning, moaning, or gasping. To control for potential confounders, patients with positive APRs (APR group) were matched with injured workers without APRs (control group) seen in the same clinic and matched for sex, age, and surgical candidacy.

Results:

Data from 1000 workers who had sustained a shoulder injury at work and who were referred for an early assessment by an orthopaedic surgeon and a physical therapist were reviewed. A total of 86 (9%) injured workers (mean age, 47 ± 11 years; 55 [64%] female) demonstrated APRs and were matched with 86 injured workers without APRs. There were no statistically significant between-group differences in the wait time, mechanism of injury, coexisting comorbidity, type of abnormality, or medication consumption. The APR group reported higher levels of disability (P < .0001) and psychological problems (P < .0001), presented with more inconsistency in range of motion (P = .04), and had more limitations at work (P = .02).

Conclusion:

The presence of an APR after a compensable shoulder injury was associated with higher reports of disability and psychological problems. Patients with positive APRs were more likely to be off work and less likely to perform full duties.

The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain

PURPOSE

This study investigated the role of anxiety sensitivity, resilience, pain catastrophizing, depression, pain fear-avoidance beliefs, and pain intensity in patients with acute back pain-related disability.

METHOD

Two hundred and thirty-two patients with acute back pain completed questionnaires on anxiety sensitivity, resilience, pain catastrophizing, fear-avoidance beliefs, depression, pain intensity, and disability.

RESULTS

A structural equation modelling analysis revealed that anxiety sensitivity was associated with pain catastrophizing, and resilience was associated with lower levels of depression. Pain catastrophizing was positively associated with fear-avoidance beliefs and pain intensity. Depression was associated with fear-avoidance beliefs, but was not associated with pain intensity. Finally, catastrophizing, fear-avoidance beliefs, and pain intensity were positively and significantly associated with acute back pain-related disability.

CONCLUSION

Although fear-avoidance beliefs and pain intensity were associated with disability, the results showed that pain catastrophizing was a central variable in the pain experience and had significant direct associations with disability when pain was acute. Anxiety sensitivity appeared to be an important antecedent of catastrophizing, whereas the influence of resilience on the acute back pain experience was limited to its relationship with depression.

Predicting Low Back Pain Outcomes: Suggestions for Future Directions

Chronic low back pain (LBP) is a common and costly musculoskeletal pain condition, and effective treatment of LBP represents a significant goal of physical therapists. Establishing a targeted track of treatment for patients with LBP at high risk for chronicity that is focused on modifiable prognostic factors could have significant personal and societal benefit. Such an approach would require that clinicians accurately predict the patients who are at an elevated risk of developing chronic LBP in the early stages of the condition. In this Viewpoint, we consider the strengths and limitations of existing literature and propose suggestions that may lead to the development of parsimonious, cost-effective, and accurate predictive models of LBP chronicity. J Orthop Sports Phys Ther 2017;47(9):588-592. doi:10.2519/jospt.2017.0607.

Utilizing Behavior Change Techniques to Elicit Adherence to Clinical Practice Guidelines

INTRODUCTION

Two 2-day continuing education seminars were developed to address the orthopedic physical therapy deficits in Guyana. Material was presented in a way to address all stages of behavior change.

METHODS

Surveys evaluating preseminar and postseminar knowledge was conducted. Chart reviews to establish adherence to clinical practice guidelines were performed.

RESULTS

Preseminar surveys revealed minimal knowledge of clinical practice guidelines, which was consistent with preseminar chart review data. Postseminar data indicate improvements in both knowledge and adherence to guidelines.

DISCUSSION

A brief series of two 2-day seminars utilizing behavior change strategies to improve adherence to clinical practice guidelines shows promise for countries and regions that rely on international health volunteers to provide clinical instruction. Because this study is limited to one situation, further studies with longer follow-up in a variety of clinical settings are recommended to support generalizability of findings.

Feasibility and Safety of a Virtual Reality Dodgeball Intervention for Chronic Low Back Pain: A Randomized Clinical Trial

Whereas the fear-avoidance model of chronic low back pain (CLBP) posits a generic avoidance of movement that is perceived as threatening, we have repeatedly shown that individuals with high fear and CLBP specifically avoid flexion of the lumbar spine. Accordingly, we developed a virtual dodgeball intervention designed to elicit graded increases in lumbar spine flexion while reducing expectations of fear and harm by engaging participants in a competitive game that is entertaining and distracting. We recruited 52 participants (48% female) with CLBP and high fear of movement and randomized them to either a game group (n = 26) or a control group (n = 26). All participants completed a pregame baseline and a follow-up assessment (4-6 days later) of lumbar spine motion and expectations of pain and harm during standardized reaches to high (easier), middle, and low (hardest to reach) targets. For 3 consecutive days, participants in the game group completed 15 minutes of virtual dodgeball between baseline and follow-up. For the standardized reaching tests, there were no significant effects of group on changes in lumbar spine flexion, expected pain, or expected harm. However, virtual dodgeball was effective at increasing lumbar flexion within and across gameplay sessions. Participants reported strong positive endorsement of the game, no increases in medication use, pain, or disability, and no adverse events. Although these findings indicate that very brief exposure to this game did not translate to significant changes outside the game environment, this was not surprising because graded exposure therapy for fear of movement among individuals with low back pain typically last 8 to 12 sessions. Because of the demonstration of safety, feasibility, and ability to encourage lumbar flexion within gameplay, these findings provide support for a clinical trial wherein the treatment dose is more consistent with traditional graded exposure approaches to CLBP.

PERSPECTIVE

This study of a virtual reality dodgeball intervention provides evidence of feasibility, safety, and utility to encourage lumbar spine flexion among individuals with CLBP and high fear of movement.

The ability of preoperative factors to predict patient-reported disability following surgery for rotator cuff pathology

PURPOSE

Minimal research has examined the prognostic ability of shoulder examination data or psychosocial factors in predicting patient-reported disability following surgery for rotator cuff pathology. The purpose of this study was to examine these factors for prognostic value in order to help clinicians and patients understand preoperative factors that impact disability following surgery.

METHODS

Sixty-two patients scheduled for subacromial decompression with or without supraspinatus repair were recruited. Six-month follow-up data were available for 46 patients. Patient characteristics, history of the condition, shoulder impairments, psychosocial factors, and patient-reported disability questionnaires were collected preoperatively. Six months following surgery, the Western Ontario Rotator Cuff Index (WORC) and global rating of change dichotomized subjects into responders versus nonresponders. Logistic regression quantified prognostic ability and created the most parsimonious model to predict outcome.

RESULTS

Being on modified job duty (OR = .17, 95%CI: 0.03-0.94), and having a worker's compensation claim (OR = 0.08, 95%CI: 0.01-0.74) decreased probability of a positive outcome, while surgery on the dominant shoulder (OR = 11.96, 95%CI: 2.91-49.18) increased probability. From the examination, only impaired internal rotation strength was a significant univariate predictor. The Fear-avoidance Beliefs Questionnaire (FABQ) score (OR = 0.95, 95%CI: 0.91-0.98) and the FABQ_work subscale (OR = 0.92, 95%CI: 0.87-0.97) were univariate predictors. In the final model, surgery on the dominant shoulder (OR = 8.9, 95%CI 1.75-45.7) and FABQ_work subscale score ≤25 (OR = 15.3, 95%CI 2.3-101.9) remained significant.

DISCUSSION

Surgery on the dominant arm resulted in greater improvement in patient-reported disability, thereby increasing the odds of a successful surgery. The predictive ability of the FABQ_work subscale highlights the potential impact of psychosocial factors on patient-reported disability. Implications for Rehabilitation Impairment-based shoulder measurements were not strong predictors of patient-reported outcome. Having high fear-avoidance behavior scores on the FABQ, especially the work subscale, resulted in a much lower chance of responding well to rotator cuff surgery as measured by self-reported disability. Having surgery on the dominant shoulder, as compared to the nondominant side, resulted in larger improvements in disability levels.

Psychometric properties of the Fear-Avoidance Beliefs Questionnaire in patients with neck pain

Objectives: To translate the Fear-Avoidance Beliefs Questionnaire and investigate the validity and reliability of the Chinese version of the questionnaire in patients with neck pain.

Design: Observational cross-sectional and prospective study.

Setting: Physiotherapy outpatient departments.

Subjects: Four samples with 476 consecutive adult patients with neck pain from four physiotherapy centres.

Methods: The original questionnaire was translated into Chinese by forward and backward translation and reviewed by a panel of experts. The subjects completed the Chinese version of the fear-avoidance questionnaire, Northwick Park Neck Pain Questionnaire, Medical Outcomes 36-Item Short-Form Health Survey and their pain intensity was measured using an 11-point pain numerical rating scale. They were observed and measured at the beginning of physiotherapy, at week 3 and at week 6 after treatment began.

Results: The questionnaire had very good content validity and test-retest reliability with an intraclass correlation coefficient of 0.81 and Cronbach’s alpha coefficient of 0.90. Spearman’s correlation coefficients between fear-avoidance and the neck pain questionnaire, the health survey (physical), health survey (mental) and pain scale were 0.56, 0.45, 0.36 and 0.34, respectively. The standard response mean and effect size at week 6 were 0.38 and 0.32, respectively. Factor analysis yielded three factors which accounted for 61.6% of the total variance of the questionnaire.

Conclusion: The Fear-Avoidance Beliefs Questionnaire is a valid and reliable tool for patients with neck pain. It has been shown to demonstrate very good content validity, a high degree of test-retest reliability and internal consistency, good construct validity and medium responsiveness.

Fear-avoidance in Recovered Burn Patients: Association with Psychological and Somatic Symptoms

Fear-avoidance, an important model in the understanding of chronic pain, has not yet been studied in patients with burns. The purpose of this study was to investigate if recovered burn patients have fear-avoidance beliefs and to explore the association with psychological and somatic symptoms. Eighty-four recovered burn patients completed self-report questionnaires. The results showed that there were fear-avoidance beliefs, but not to a large extent. Beta coefficients from multiple regression analyses indicated a strong association between fear-avoidance and problems with work, heat sensitivity and arousal symptoms. The model was capable of explaining 73 per cent of the variance in fear-avoidance beliefs.

Le Retour Thérapeutique au Travail comme une intervention de réadaptation centralisée dans le milieu de travail: Description et fondements théoriques

L'ergothérapeute est impliqué de façon de plus en plus importante dans l'intervention auprès des travailleurs présentant des lésions musculo-squelet-tiques d'origine professionnelle. Dans ce domaine, une intervention innovatrice appelée le Retour Thérapeutique au Travail a été développée. Celle-ci intègre rapidement au programme de réadaptation, le retour supervisé de l'individu blessé à son poste de travail régulier. L'utilisation et l'exploitation de l'environnement naturel du travailleur par l'ergothérapeute devient un élément fondamental de ce processus de réadaptation au travail. Cet article décrit brièvement les différentes étapes de cette intervention et les fondements théoriques qui la supportent. Par ailleurs, le Retour Thérapeutique au Travail s'inscrit parfaitement dans les nouvelles orientations de l'ergothérapie axées sur une pratique intégrée dans le milieu communautaire.

Can a back pain screening tool help classify patients with acute pain into risk levels for chronic pain?

BACKGROUND

The 9-item STarT-Back screening tool was developed in primary care patients with low back pain (LBP) to identify those at greatest risk for chronic pain and requiring targeted treatment. We conducted a secondary data analysis study to examine the performance of comparable questionnaire items in a sample of primary care patients with well-defined acute LBP.

METHODS

In a prospective cohort study, 605 primary care patients with LBP of less than 30 days answered a questionnaire with 6 items identical and 3 items analogous to the 9-item STarT-Back. Participants were followed up at 6 months and 2 years. STarT-Back rules were applied to classify participant's risk of chronic LBP, and the performance of the screening items in predicting outcomes was assessed using likelihood ratios.

RESULTS

The proportion of patients with chronic pain at follow-up was considerably lower (6 months: 22%; 2 years: 25%) than in the STarT-Back validation cohort (40%) of patients with pain of any duration. The probability of developing chronic pain given a high-risk designation by items similar to the STarT-Back increased the pre-test probability to 31% and 35%. Likelihood ratios were close to 1.

CONCLUSIONS

A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. The results suggest caution when applying the STarT-Back in patients with acute LBP and a need to consider a modification of its cut-offs.

A systematic review of prognostic factors for distal upper limb pain

BACKGROUND

Musculoskeletal pain in the distal upper limb is relatively common, can be a cause of disability, presents a high cost to society and is clinically important. Previous reviews of prognostic factors have focused on pain in the proximal upper limb, whole upper extremity or isolated regions of the distal upper limb.

AIM

To identify factors that predict outcome of distal upper limb pain.

STUDY DESIGN

Systematic review.

METHOD

Eight bibliographic databases were searched from inception to March 2014. Eligible articles included adults with pain anywhere in the distal upper limb at baseline from randomised controlled trials with a waiting list, expectant policy or usual care group, or observational studies where no treatment or usual care was provided. Data describing the association between a putative prognostic factor and pain or functional outcome at follow-up were required. Quality was assessed using the Quality in Prognostic Studies tool.

RESULTS

Seven articles reporting on six studies were identified. Heterogeneity of study populations and outcome measures prevented a meta-analysis so a narrative synthesis of results was undertaken. Three factors (being female, a longer duration of the complaint at initial presentation and having musculoskeletal pain in multiple locations) were significantly associated with poor pain outcome in more than one study. Being female was the only factor significantly associated with poor functional outcome in more than one study.

CONCLUSIONS

A range of sociodemographic, pain-related, occupational and psychosocial prognostic factors for distal upper limb pain outcomes were investigated in studies included in the review. However, due to the lack of commonality of factors investigated and lack of consistency of results across studies, there is limited evidence for predictors of distal upper limb pain outcomes. Further research is required to identify prognostic factors of distal upper limb pain, particularly modifiable factors that may influence management.

Spinal pain: current understanding, trends, and the future of care

This commissioned review paper offers a summary of our current understanding of nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem, requiring management that addresses both the physical and psychosocial components of the pain experience. We propose a model of care that includes the necessary components of care services that would address the multidimensional nature of spinal pain. Emerging care services that tailor care to the individual person with pain seems to achieve better outcomes and greater consumer satisfaction with care, while most likely containing costs. However, we recommend that any model of care and care framework should be developed on the basis of a multidisciplinary approach to care, with the scaffold being the principles of evidence-based practice. Importantly, we propose that any care services recommended in new models or frameworks be matched with available resources and services - this matching we promote as the fourth principle of evidence-based practice. Ongoing research will be necessary to offer insight into clinical outcomes of complex interventions, while practice-based research would uncover consumer needs and workforce capacity. This kind of research data is essential to inform health care policy and practice.

Chronic Pain-related Disability: Current Scientific Rationale and Recommendations for Practice

The present paper concerns the prevention and management of disability due to chronic pain. The problem of disabling chronic pain is presented and the impact on the community is highlighted. The scientific rationale for current approaches to management is discussed and the available empirical evidence reviewed. In particular, the present paper advocates application of the biopsychosocial model for the prevention and management of chronic pain-related disability. As such, the components of the biopsychosocial model are reviewed and recommendations for rehabilitation counselling practice are presented.

[Coping resources in a sample of chronic low back pain patients. Evaluation of the questionnaire for back pain]

BACKGROUND

The coping resources questionnaire for back pain (FBR) uses 12 items to measure the perceived helpfulness of different coping resources (CRs, social emotional support, practical help, knowledge, movement and relaxation, leisure and pleasure, spirituality and cognitive strategies). The aim of the study was to evaluate the instrument in a clinical patient sample assessed in a primary care setting.

SAMPLE AND METHODS

The study was a secondary evaluation of empirical data from a large cohort study in general practices. The 58 participating primary care practices recruited patients who reported chronic back pain in the consultation. Besides the FBR and a pain sketch, the patients completed scales measuring depression, anxiety, resilience, sociodemographic factors and pain characteristics. To allow computing of retested parameters the FBR was sent to some of the original participants again after 6 months (90% response rate). We calculated consistency and retest reliability coefficients as well as correlations between the FBR subscales and depression, anxiety and resilience scores to account for validity. By means of a cluster analysis groups with different resource profiles were formed. Results.

RESULTS

For the study 609 complete FBR baseline data sets could be used for statistical analysis. The internal consistency scores ranged fromα=0.58 to α=0.78 and retest reliability scores were between rTT=0.41 and rTT=0.63. Correlation with depression, fear and resilience ranged from r=-0.38 to r=0.42. The cluster analysis resulted in four groups with relatively homogenous intragroup profiles (high CRs, low spirituality, medium CRs, low CRs). The four groups differed significantly in fear and depression (the more inefficient the resources the higher the difference) as well as in resilience (the more inefficient the lower the difference). The group with low CRs also reported permanent pain with no relief. The groups did not otherwise differ.

CONCLUSIONS

The FBR is an economic instrument that is suitable for practical use e.g. in primary care practices to identify strengths and deficits in the CRs of chronic pain patients that can then be specified in face to face consultation. However, due to the rather low reliability, the use of subscales for profile differentiation and follow-up measurement in individual diagnoses is limited.

Development and Validation of the Athlete Fear Avoidance Questionnaire

CONTEXT

The fear-avoidance model was developed in an attempt to explain the process by which "pain experience" and "pain behavior" become dissociated from the actual pain sensation in individuals who manifest the phenomenon of exaggerated pain perception. High levels of fear avoidance can lead to chronic pain and disability and have successfully predicted rehabilitation time in the work-related-injury population. Existing fear-avoidance questionnaires have all been developed for the general population, but these questionnaires may not be specific enough to fully assess fear avoidance in an athletic population that copes with pain differently than the general population.

OBJECTIVE

To develop and validate the Athlete Fear Avoidance Questionnaire (AFAQ).

DESIGN

Qualitative research to develop the AFAQ and a cross-sectional study to validate the scale.

PATIENTS OR OTHER PARTICIPANTS

For questionnaire development, a total of 8 experts in the fields of athletic therapy, sport psychology, and fear avoidance were called upon to generate and rate items for the AFAQ. For determining concurrent validity, 99 varsity athletes from various sports participated.

DATA COLLECTION AND ANALYSIS

A total of 99 varsity athletes completed the AFAQ, the Fear-Avoidance Beliefs Questionnaire, and the Pain Catastrophizing Scale. We used Pearson correlations to establish concurrent validity.

RESULTS

Concurrent validity was established with significant correlations between the AFAQ and the Fear Avoidance Beliefs Questionnaire-Physical Activity (r = 0.352, P > .001) as well as with the Pain Catastrophizing Scale (r = 0.587, P > .001). High internal consistency of our questionnaire was established with a Cronbach α coefficient of 0.805. The final version of the questionnaire includes 10 items with good internal validity (P < .05).

CONCLUSIONS

We developed a questionnaire with good internal and external validity. The AFAQ is a scale that measures sport-injury-related fear avoidance in athletes and could be used to identify potential psychological barriers to rehabilitation.

Individual and gender differences in subjective and objective indices of pain: gender, fear of pain, pain catastrophizing and cardiovascular reactivity

According to fear-avoidance models of pain perception, heightened fear of pain may increase disruptive effects of pain; however, the extent to which this affects self-reported pain severity versus physiological indices of pain is not well delineated. The current study examined self-report measures and physiological indices of pain during a cold pressor (CP) task. Individual differences in fear of pain and pain catastrophizing were also assessed via questionnaire. The primary aim of the current study was to examine the extent to which individual differences associated with fear and catastrophizing in response to pain influences subjective and physiological measures of pain. A secondary aim was to examine gender differences associated with response to pain. Average subjective pain ratings were higher for females than males. In contrast, males exhibited higher systolic and diastolic reactivity in response to the CP task relative to females, as well as failure to fully recover to baseline levels. Follow-up correlational analyses revealed that subjective pain ratings were positively associated with fear of pain in both sexes, but were not associated with cardiovascular indices. These results suggest that fear of pain and pain catastrophizing do not influence cardiovascular responses to induced pain. Further research is necessary in order to determine whether these gender differences in blood pressure and heart rate response profiles are due to biological or psychosocial influences. Results support the notion that fear of pain increases subjective pain ratings, but does not influence cardiovascular responses during CP pain-induction.

The effects of the CORE programme on pain at rest, movement-induced and secondary pain, active range of motion, and proprioception in female office workers with chronic low back pain: a randomized controlled trial

OBJECTIVE

To investigate the effects of the CORE programme on pain at rest, movement-induced pain, secondary pain, active range of motion, and proprioception deficits in female office workers with chronic low back pain.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation clinics.

SUBJECTS

A total of 53 participants with chronic low back pain were randomized into the CORE group and the control group.

INTERVENTION

CORE group participants underwent the 30-minute CORE programme, five times per week, for eight weeks, with additional use of hot-packs and transcutaneous electrical nerve stimulation, while the control group used only hot-packs and transcutaneous electrical nerve stimulation.

MAIN MEASURES

Participants were evaluated pretest, posttest, and two months after the intervention period to measure resting and movement-induced pain, pressure pain as secondary pain, active range of pain-free motion, and trunk proprioception.

RESULTS

Pain intensity at rest (35.6 ±5.9 mm) and during movement (39.4 ±9.1 mm) was significantly decreased in the CORE group following intervention compared with the control group. There were significant improvements in pressure pain thresholds (quadratus lumborum: 2.2 ±0.7 kg/cm(2); sacroiliac joint: 2.0 ±0.7 kg/cm(2)), active range of motion (flexion: 30.8 ±14.3°; extension: 6.6 ±2.5°), and proprioception (20° flexion: 4.3 ±2.4°; 10° extension: 3.1 ±2.0°) in the CORE group following intervention (all p < 0.05). These improvements were maintained at the two-month follow-up. The control group did not show significant improvements in any measured parameter.

CONCLUSION

The CORE programme is an effective intervention for reducing pain at rest and movement-induced pain, and for improving the active range of motion and trunk proprioception in female office workers with chronic low back pain.

The STarT Back Screening Tool for prediction of 6-month clinical outcomes: relevance of change patterns in outpatient physical therapy settings

STUDY DESIGN

Observational cohort.

OBJECTIVES

To describe changes in STarT Back Tool (SBT) categorization following 4 weeks of outpatient physical therapy and to evaluate predictive capabilities of SBT categorization when administered at multiple time points.

BACKGROUND

Initial assessment information is commonly used to predict long-term outcomes but does not account for changes that occur following initiation of treatment. Changes in SBT categorization during the course of treatment have potential to provide additional prognostic information that could positively impact management of low back pain.

METHODS

Patients (n = 123) receiving nonstandardized physical therapy care for low back pain were administered the SBT at intake and 4 weeks later to evaluate SBT changes, which were described as improved (SBT categorization changed from medium to low, high to low, or high to medium risk), stable (SBT categorization remained low or medium risk), or worsened (SBT categorization changed from low to medium, low to high, medium to high, or remained high risk). Clinical outcomes consisted of pain intensity and self-reported disability. Relative contributions of SBT categorization (at intake and 4 weeks) and SBT change patterns as predictors of 6-month clinical outcomes were assessed using separate multiple-regression models, while controlling for other prognostic variables.

RESULTS

Most patients (81.8%) initially categorized as SBT high risk were categorized differently by the SBT at 4 weeks. Eleven percent of patients were described as worsened, based on SBT-category change patterns at 4 weeks. Prediction of 6-month disability scores was improved when considering intake, 4-week, or 4-week change for SBT categorization, with SBT high risk consistently providing unique contributions.

CONCLUSION

Repeated SBT assessment during the episode of physical therapy has potential to provide additional information for prediction of disability at 6 months. Future studies should investigate optimal management strategies for patients who have worsened SBT risk following physical therapy intervention.

LEVEL OF EVIDENCE

Prognosis, level 2b.

Accuracy of physical therapists' prognosis of low back pain from the clinical examination: a prospective cohort study

OBJECTIVES

To investigate, in patients with chronic or recurrent low back pain (LBP), the predictive validity of history items, demographic variables, outcome measure questionnaire scores, clinical examination items, and physical therapists' (PTs') summative estimation of prognosis on a four-point scale. Little is known about the ability of PTs to predict functional outcomes for patients with LBP.

METHODS

This was a multi-centre prospective cohort study of 138 patients with LBP. We used backward stepwise linear regression modelling to estimate the predictive validity of the baseline variables. The endpoint outcome measure was the 18-item Roland-Morris Disability Questionnaire (RM18) at 1 year.

RESULTS

Of 138 patients with LBP recruited, 89 (64%) completed follow-up at one year. Univariate analysis indicated that PTs' opinion of prognosis (P = 0.01) and eleven other baseline variables were significantly associated with RM18 at 12 months. In the final multivariate model PTs' opinion of prognosis (P = 0.022; beta = 0.73, CI 0.55, 0.95), an abnormality detected by passive physiological flexion testing (P = 0.043, beta = 1.61, CI 1.02, 2.57), heavy work (P = 0.069, beta = 0.80, CI 0.62, 1.01), and age (P = 0.079, beta = 1.01 CI 0.99, 1.04) were independent prognostic factors for RM18 outcome, explaining 24% of the variance in the model.

CONCLUSIONS

Musculoskeletal PTs' summative clinical impression regarding prognosis, following a clinical examination, provides a valid predictive estimation of functional outcome at 1 year in patients with chronic or recurrent LBP.

PTSD and pain: exploring the impact of posttraumatic cognitions in veterans seeking treatment for PTSD

OBJECTIVE

Previous research has demonstrated a significant relationship between posttraumatic stress disorder (PTSD) and pain. While several models attempt to explain this relationship, significant questions remain regarding factors that may play a role in this interaction. The purpose of this study was to determine whether posttraumatic cognitions mediate the relationship between PTSD and pain.

DESIGN

The sample comprised 136 veterans who presented to the VA Ann Arbor Health Care System seeking evaluation and treatment in the PTSD clinic. Participants completed the Clinician-Administered PTSD Scale, the Posttraumatic Cognitions Inventory, and Brief Pain Inventory-Short Form, along with other assessments as part of their evaluation.

RESULTS

This study showed that the majority of patients (86.8%) reported some problems with pain. Further, the findings indicate that there is a significant relationship between PTSD severity and pain severity. Posttraumatic cognitions were not related to the level of pain experienced, but they were related to pain interference in this population.

CONCLUSIONS

In particular, negative cognitions regarding the self were associated with the level of pain-related interference, and partially mediated the relationship between PTSD and pain. The clinical implications of these findings are discussed.

The prognostic value of electrodiagnostic testing in patients with sciatica receiving physical therapy

PURPOSE

To investigate the prognostic value of electrodiagnostic testing in patients with sciatica receiving physical therapy.

METHODS

Electrodiagnostic testing was performed on 38 patients with sciatica participating in a randomized trial comparing different physical therapy interventions. Patients were grouped and analyzed according to the presence or absence of radiculopathy based on electrodiagnostic testing. Longitudinal data analysis was conducted using multilevel growth modeling with ten waves of data collected from baseline through the treatment and post-treatment periods up to 6 months. The primary outcome measure was changes in low back pain-related disability assessed using the Roland and Morris disability questionnaire (RMDQ).

RESULTS

Patients with radiculopathy (n = 19) had statistically significant and clinically meaningful improvements in RMDQ scores at every post-treatment follow-up occasion regardless of treatment received. The final multilevel growth model revealed improvements in RMDQ scores in patients with radiculopathy at the 6-week (-8.1, 95 % CI -12.6 to -2.6; P = 0.006) and 6-month (-4.1, 95 % CI -7.4 to -0.7; P = 0.020) follow-up occasions compared to patients without radiculopathy. Treatment group was not a significant predictive factor at any follow-up occasion. An interaction between electrodiagnostic status and time revealed faster weekly improvements in RMDQ scores in patients with radiculopathy at the 6-week (-0.72, 95 % CI -1.4 to -0.04; P = 0.040) through the 16-week (-0.30, 95 % CI, -0.57 to -0.04; P = 0.028) follow-up occasions compared to patients without radiculopathy.

CONCLUSIONS

The presence of lumbosacral radiculopathy identified with electrodiagnostic testing is a favorable prognostic factor for recovery in low back pain-related disability regardless of physical therapy treatment received.

Simulation in spinal diseases

Simulation is frequent in spinal disease, resulting in problems for specialists like Orthopedic Surgeons, Neurosurgeons, Reumathologists, etc. Simulation requires demonstration of the intentional production of false or exaggerated symptoms following an external incentive. The clinician has difficulties in demonstrating these criteria, resulting in misdiagnosis of simulation or misinterpretation of the normal patient as a simulator, with the possibility of iatrogenic distress and litigation. We review simulation-related problems in spine, proposing a terminological, as well as a diagnostic strategy including clinical and complementary diagnosis, as a way to avoid misinterpretation and minimize the iatrogenic distress and liability Based on the clinical-Forensic author's expertise, the literature is analyzed and the terminology readdressed to develop new terms (inconsistences, incongruences, discrepancies and contradictions). Clinical semiology and complementary test are adapted to the new scenario. Diagnostic strategy relies on anamnesis, clinical and complementary tests, adapting them to a uniform terminology with clear meaning of signs and symptoms.

The effectiveness of shoe insoles for the prevention and treatment of low back pain: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Low back pain (LBP) is a significant public health problem in Western industrialised countries and has been reported to affect up to 80% of adults at some stage in their lives. It is associated with high health care utilisation costs, disability, work loss and restriction of social activities. An intervention of foot orthoses or insoles has been suggested to reduce the risk of developing LBP and be an effective treatment strategy for people suffering from LBP. However, despite the common usage of orthoses and insoles, there is a lack of clear guidelines for their use in relation to LBP. The aim of this review is to investigate the effectiveness of foot orthoses and insoles in the prevention and treatment of non specific LBP.

METHODS

A systematic search of MEDLINE, CINAHL, EMBASE and The Cochrane Library was conducted in May 2013. Two authors independently reviewed and selected relevant randomised controlled trials. Quality was evaluated using the Cochrane Collaboration Risk of Bias Tool and the Downs and Black Checklist. Meta-analysis of study data were conducted where possible.

RESULTS

Eleven trials were included: five trials investigated the treatment of LBP (n=293) and six trials examined the prevention of LBP (n=2379) through the use of foot orthoses or insoles. Meta-analysis showed no significant effect in favour of the foot orthoses or insoles for either the treatment trials (standardised mean difference (SMD) -0.74, CI 95%: -1.5 to 0.03) or the prevention trials (relative risk (RR) 0.78, CI 95%: 0.50 to 1.23).

CONCLUSIONS

There is insufficient evidence to support the use of insoles or foot orthoses as either a treatment for LBP or in the prevention of LBP. The small number, moderate methodological quality and the high heterogeneity of the available trials reduce the strength of current findings. Future research should concentrate on identification of LBP patients most suited to foot orthoses or insole treatment, as there is some evidence that trials structured along these lines have a greater effect on reducing LBP.

Psychometric properties of the Japanese version of the Fear-Avoidance Beliefs Questionnaire (FABQ)

BACKGROUND

The Fear-Avoidance Beliefs Questionnaire (FABQ) is useful for measuring fear-avoidance beliefs in patients with low back pain (LBP); however, no psychometrically validated Japanese version is available. The objective of this study was to evaluate reliability and validity of the Japanese version of the FABQ for use with Japanese workers with LBP.

METHODS

This was conducted as a web-based survey. Both confirmatory and exploratory factor analysis were performed to examine domain structure of the Japanese version of the FABQ. For reliability, internal consistency was assessed with Cronbach's alpha coefficient. For concurrent validity, correlation coefficients between the FABQ and the Pain Catastrophizing Scale (PCS) were calculated. For known-group validity, the relationship between FABQ score and clinical variables such as pain and depression was examined.

RESULTS

Analyses were based on responses of 1,786 adult Japanese workers with LBP. Factor analysis using the principal factor method with promax rotation revealed two factors, work and physical activity, in accordance with the domain structure of the original version of the scale. For reliability, acceptable internal consistency was demonstrated with Cronbach's alpha coefficient of 0.882 and 0.783 for each subscale. For concurrent validity, significantly moderate correlations were demonstrated between FABQ subscales and PCS subscales (r = 0.30-0.39). For known-group validity, as hypothesized, significantly higher FABQ subscale scores were observed in workers who had stronger pain, who experienced routine work disability with sick leave, who experienced recurrence of LBP, and who had depressed mood.

CONCLUSIONS

This analysis showed that the Japanese version of the FABQ is psychometrically reliable and valid to detect fear-avoidance beliefs in Japanese workers with LBP.