The Lancet Series call to action to reduce low value care for low back pain: an update

Co-creating a Choosing Wisely leaflet supporting the reduction of imaging usage in low back pain management - A multi-method study

OBJECTIVE

The objective was to co-create an information resource in the form of a leaflet, to be distributed in clinical settings, websites or social media targeting people with low back pain.

METHODS

This multi-method study was conducted in four stages: literature search, input from practice consultants, program theory development, and think-aloud interviews with people experiencing low back pain. Each stage was followed by a consensus meeting in which the steering group refined the leaflet based on the emerging knowledge.

RESULTS

The literature search highlighted patients' need for easy-to-understand information about their back pain diagnosis, management strategies, social activities, work and solutions for supported self-management strategies. Practice consultants emphasized concise, relatable content. The program theory identified potential mechanisms for content creation, development, and implementation of the leaflet, such as addressing patient concerns, reducing diagnostic uncertainty, insights into management options, and validation. Think-aloud interviews with 18 people living with low back pain informed the iteration of the leaflet, enhancing language clarification and content comprehension.

CONCLUSIONS

We co-created a new Choosing Wisely leaflet, created with end-users in mind, specifically focused on reducing unnecessary imaging for low back pain.

PRACTICE IMPLICATIONS

This leaflet may support clinical settings in delivering evidence-based approaches and supporting self-management.

Dissemination Strategies for Clinical Practice Guidelines Focused on Imaging for Low Back Pain: A Scoping Review

OBJECTIVE

To investigate campaigns developed for the dissemination of clinical practice guidelines for the appropriate use of imaging for low back pain.

METHOD

A scoping review was conducted to identify resources which report on dissemination strategies for low back pain imaging clinical practice guidelines. A database search was conducted of MEDLINE, CINAHL, Cochrane Reviews, Scopus, Google, Google Scholar and National Health Service Websites. The full text of relevant resources identified from the title and abstract screen were retrieved and assessed for inclusion eligibility.

RESULTS

The initial search identified 1087 resources. Following a title, abstract and full-text screen, 26 resources were included for final synthesis. Relevant data were extracted and categorised into the following three key components: (1). Location of the campaign, (2). Campaign details, (3). Dissemination strategies as defined by five methods (educational resources, presentations and interactive interventions, media form, clinical decision support, and other). Educational resources and interactive interventions were the most commonly used strategies, with media resources implemented the least.

CONCLUSION

Low back pain imaging clinical practice guidelines have been disseminated to clinicians at regional and national levels; however, there are few international campaigns. The comprehensive list of dissemination strategies included in this study has created a foundation to facilitate the design of future campaigns to enhance the scope of trialled strategies to consider the complexities of clinical practice and its ever present need to change.

Posterior allograft sacroiliac joint fusion with pre-operative mapping

Background

Low back pain is a highly prevalent and disabling condition. Sacroiliac joint dysfunction is prevalent in up to 62 % of some populations and is a common origin of low back pain. The posterior approach for minimally invasive sacroiliac joint fusion with an allograft is still relatively novel, with limited studies examining its safety and efficacy.

Objective

The objective of our study was to analyze changes in pain and opioid usage for patients who underwent this procedure with pre-operative mapping after exhausting conservative treatment methods.

Methods

This was a single-center, retrospective study with all cases completed by a single interventional pain physician. Outcomes regarding pain and opioid usage were extracted from electronic medical records, Georgia Prescription Drug Monitoring Program reports, and all other available state databases for 208 consecutive patients who underwent the minimally invasive sacroiliac joint fusion procedure with the LinQ Fusion Implant (PainTeq, Tampa, FL) after pre-operative mapping between August 2019 and October 2022. Pain was assessed using the Numerical Rating Scale (NRS), and opioid consumption was measured using Morphine Milligram Equivalents (MME).

Results

NRS scores decreased from 7.23 ± 1.82 at baseline to 1.16 ± 1.35 at the final available follow-up (p < 0.001). Pain improvements ranged from 40 to 100 %, and all patients reported at least some improvement post-intervention. 205 of the 208 patients reported an improvement in pain of at least 50 %. MME reduced from 20.74 ± 26.33 mg to 10.00 ± 18.69 mg (p < 0.001).

Conclusion

Posterior allograft sacroiliac joint fusion significantly reduces pain and opioid consumption. Pre-operative mapping is beneficial but requires more evidence to elucidate its role in optimizing implant placement.

Benefits and harms of exercise therapy and physical activity for low back pain: An umbrella review

PURPOSE

The purpose of this umbrella review is to synthesize the evidence from systematic reviews on the benefits and harms of exercise therapy and physical activity (PA) for the secondary prevention and management of low back pain (LBP).

METHODS

An umbrella review was conducted to evaluate the effectiveness of exercise therapy and PA in the management and secondary prevention of LBP. A systematic search was performed in Medline via Ovid, CINAHL, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and Physiotherapy Evidence Database (PEDro), including reference lists of relevant reviews, covering studies published between January 2010 and May 20, 2024. Eligible studies were systematic reviews of randomized controlled trials and observational studies, with or without meta-analyses. The primary outcome for secondary prevention was LBP recurrence, while for management, primary outcomes included pain intensity and disability, with adverse events as secondary outcomes. Data were extracted across immediate, short-term, intermediate, and long-term follow-up periods. The GRADE framework was used to assess the certainty of evidence, and the AMSTAR tool was applied by 2 independent reviewers (JC, QL, and/or DXMW) to evaluate the quality of the included reviews. The study was prospectively registered on the Open Science Framework (OSF) (registration DOI: https://doi.org/10.17605/OSF.IO/9P).

RESULTS

A total of 70 systematic reviews were included, 43 with meta-analyses, 7 with network meta-analyses, and 20 without meta-analyses. Six (out of 10) reviews with meta-analyses for secondary prevention indicated a small benefit from general exercises and leisure-time PA (low-to-moderate certainty). For LBP management, 35 (out of 36) reviews reported that exercise therapies such as Pilates, motor control, mixed exercise, Tai Chi, water-based exercises, and yoga showed small beneficial effects on pain and disability compared to minimal intervention mainly in the short-term (low-to-moderate certainty). Seven network meta-analyses favored motor control and Pilates over other forms of exercise to reduce pain (low certainty). Adverse events were reported in less than 31% of the reviews, predominantly involving post-exercise soreness and temporary increases in pain, mainly in yoga-related studies. Adverse events were considered minor, and no serious adverse events were reported.

CONCLUSION

There is low-to-moderate certainty that exercise therapy and leisure-time PA are beneficial for improving pain and preventing the recurrence of LBP. However, evidence on the potential harms of these interventions is limited, and adverse events related to exercise and PA remain under-investigated.

Navigating complexities: clinicians' experiences and systemic challenges in the implementation of evidence-based practice for chronic low back pain - a qualitative study

PURPOSE

Implementation of evidence-based practice (EBP) for chronic low back pain (CLBP) is poor. This study aimed to investigate the factors that influence exercise-based clinicians' implementation of EBP for people with CLBP.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 40 clinicians (20 physiotherapists and 20 accredited exercise physiologists). Interviews explored clinicians' definition of EBP, understanding of EBP in CLBP management, barriers and enablers to EBP, and the impact of these factors on EBP implementation. Interviews were analysed using reflexive thematic analysis.

RESULTS

A complex interplay among clinician factors, systemic factors, and patient interactions was identified. Clinicians encountered challenges stemming from their misconceptions about EBP, which influenced their perspective(s) on its implementation. Clinicians expressed the challenges of implementing EBP when navigating patient expectations and beliefs, experiencing external pressures from funders and business models, and the subsequent impacts on their well-being. Continuing professional development, support from community, and workplaces that prioritised EBP enhanced clinicians' ability to make decisions that accommodate for the complexities of CLBP and better align with EBP.

CONCLUSION

A variety of factors impact exercise-based clinicians' implementation of EBP. The interaction between these factors greatly influences clinicians' ability to engage in and implement EBP in clinical practice.

Comparing the efficacy of two E-learning programs on physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management: A randomized trial

BACKGROUND

Physiotherapists play a crucial role in managing patients with musculoskeletal pain. However, their training often lacks focus on pain management.

OBJECTIVES

This randomized controlled trial evaluated the effects of two e-learning programs on physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management.

METHODS

Eligible participants had active professional registration, treated patients with musculoskeletal pain, and had internet access. Participants were randomized into two groups (video-based and booklet-based), with interventions lasting 5 weeks. Assessments were conducted at baseline, 6 weeks (T1), and 12 weeks (T2) using the Neurophysiology of Pain Questionnaire, a pain attitude survey, and self-reported confidence.

RESULTS

A total of 211 physiotherapists were randomized (video = 106; booklet = 105). Both groups improved pain neurophysiology knowledge, with the booklet group scoring higher at T1 (adjusted mean difference = 1.25, 95%CI = 0.93 to 1.58) and T2 (adjusted mean difference = 1.30, 95%CI = 0.97 to 1.63). Attitudes varied: the booklet group improved in emotion (adjusted mean difference = -0.19, 95%CI = -0.35 to -0.03) and control (adjusted mean difference = -0.20, 95%CI = -0.37 to -0.03) at T2, while the video group improved in solicitude (adjusted mean difference = -0.37, 95% CI: 0.55 to -0.19) and disability at T1 and T2. No significant effects were found in the medical cure domain, and no interaction effects were observed in the physical harm domain. Confidence increased in both groups, with no between-group differences.

CONCLUSION

Both e-learning programs effectively enhanced physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management, demonstrating the value of e-learning for continuing education.

Appropriateness of lumbar spine imaging in patients presenting to the emergency department with low back pain in a Western Australian tertiary hospital

BACKGROUND

The Australian Rheumatology Association identified the use of imaging in patients with low back pain without indication of serious pathology as a low-value practice.

AIMS

To determine the appropriateness of diagnostic lumbar spine imaging requests in patients with low back pain presenting to a Western Australian hospital's emergency department.

METHODS

We conducted a retrospective review of all adult patients (18 years and older) who presented with low back pain to the Fiona Stanley Hospital emergency department from 1 July 2020 to 31 December 2020. The appropriateness of the imaging requests was judged using the American College of Radiology's Appropriateness Criteria. The number and proportion of appropriate and inappropriate lumbar spine imaging requests were reported overall and by imaging modality together with reasons for the judgements.

RESULTS

A total of 1459 patients were included. Three hundred eight patients (21.1%) received lumbar spine imaging requests, with 350 diagnostic imaging requests eligible for analysis. Two hundred eighty (80.0%) imaging requests were judged to be appropriate (194/253 (76.7%) plain radiographs, 57/66 (86.4%) computed tomography, 29/31 (93.5%) magnetic resonance imaging). The most common reasons for an appropriate imaging request were suspected vertebral fracture (n = 223, 79.6%), followed by malignancy (n = 26, 9.3%). Of the 70 inappropriate imaging requests, 62 (88.6%) requests occurred in the absence of alerting features and eight (11.4%) requests were the wrong choice of modality.

CONCLUSIONS

Four in five lumbar spine imaging requests for investigating low back pain were appropriate. Of the inappropriate requests, the most common reason was the absence of alerting features, while a small number were the incorrect imaging modality.

Implementation of the American- College of Physicians Guideline for Low Back Pain (IMPACt-LBP): protocol for a healthcare systems embedded multisite pragmatic cluster-randomised trial

INTRODUCTION

Low back pain (LBP) is a key source of medical costs and disability, impacting over 31 million Americans at any given time and resulting in US$100-US$200 billion per year in total healthcare costs. LBP is one of the leading causes of ambulatory care visits to US physicians; problematically, these visits often result in treatments such as opioids, surgery or advanced imaging that can lead to more harm than benefit. The American College of Physicians (ACP) Guideline for Low Back Pain recommends patients receive non-pharmacological interventions as a first-line treatment. Roadmaps exist for multidisciplinary collaborative care that include well-trained primary contact clinicians with specific expertise in the treatment of musculoskeletal conditions, such as physical therapists and doctors of chiropractic, as first-line providers for LBP. These clinicians, sometimes referred to as primary spine practitioners (PSPs) routinely employ many of the non-pharmacological approaches recommended by the ACP guideline, including spinal manipulation and exercise. Important foundational work has demonstrated that such care is feasible and safe, and results in improved physical function, less pain, fewer opioid prescriptions and reduced utilisation of healthcare services. However, this treatment approach for LBP has yet to be widely implemented or tested in a multisite clinical trial in real-world practice.

METHODS AND ANALYSIS

The Implementation of the American College of Physicians Guideline for Low Back Pain trial is a health system-embedded pragmatic cluster-randomised trial that will examine the effect of offering initial contact with a PSP compared with usual primary care for LBP. Twenty-six primary care clinics within three healthcare systems were randomised 1:1 to PSP intervention or usual primary care. Primary outcomes are pain interference and physical function using the Patient-Reported Outcomes Measurement Information System Short Forms collected via patient self-report among a planned sample of 1800 participants at baseline, 1, 3 (primary end point), 6 and 12 months. A subset of participants enrolled early in the trial will also receive a 24-month assessment. An economic analysis and analysis of healthcare utilisation will be conducted as well as an evaluation of the patient, provider and policy-level barriers and facilitators to implementing the PSP model using a mixed-methods process evaluation approach.

ETHICS AND DISSEMINATION

The study received ethics approval from Advarra, Duke University, Dartmouth Health and the University of Iowa Institutional Review Boards. Study data will be made available on completion, in compliance with National Institutes of Health data sharing policies.

TRIAL REGISTRATION NUMBER

NCT05626049.

Models of care for managing non-specific low back pain

BACKGROUND

Alternative care models seek to improve the quality or efficiency of care, or both, and thus optimise patient health outcomes. They provide the same health care but change how, when, where, or by whom health care is delivered and co-ordinated. Examples include care delivered via telemedicine versus in-person care or care delivered to groups versus individual patients.

OBJECTIVES

To assess the effects of alternative models of evidenced-based care for people with non-specific low back pain on the quality of care and patient self-reported outcomes and to summarise the availability and principal findings of economic evaluations of these alternative models.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries up to 14 June 2024, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials comparing alternative care models to usual care or other care models. Eligible trials had to investigate care models that changed at least one domain of the Cochrane EPOC delivery arrangement taxonomy and provide the same care as the comparator arm. Participants were individuals with non-specific low back pain, regardless of symptom duration. Main outcomes were quality of care (referral for/receipt of lumbar spine imaging, prescription/use of opioids, referral to a surgeon/lumbar spine surgery, admission to hospital for back pain), patient health outcomes (pain, back-related function), and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was alternative models of care versus usual care at closest follow-up to 12 months.

MAIN RESULTS

Fifty-seven trials (29,578 participants) met our inclusion criteria. Trials were primarily set within primary care (18 trials) or physiotherapy practices (15 trials) in high-income countries (51 trials). Forty-eight trials compared alternative models of care to usual care. There was substantial clinical diversity across alternative care models. Alternative care models most commonly differed from usual care by altering the co-ordination/management of care processes (18 trials), or by utilising information and communication technology (10 trials). Moderate-certainty evidence indicates that alternative care models probably result in little difference in referral for or receipt of any lumbar spine imaging at follow-up closest to 12 months compared to usual care (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.86 to 0.98; I2 = 2%; 18 trials, 16,157 participants). In usual care, 232/1000 people received lumbar spine imaging compared to 213/1000 people who received alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). Moderate-certainty evidence suggests that alternative care models probably result in little or no difference in the prescription or use of opioid medication at follow-up closest to 12 months compared to usual care (RR 0.95, 95% CI 0.89 to 1.03; I2 = 0%; 15 trials, 13,185 participants). In usual care, 349 out of 1000 people used opioid medication compared to 332 out of 1000 people in alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter referral for or use of lumbar spine surgery at follow-up closest to 12 months compared to usual care as the certainty of the evidence was very low (odds ratio (OR) 1.04, 95% CI 0.79 to 1.37; I2 = 0%; 10 trials, 4189 participants). We downgraded the certainty of the evidence by three levels due to very serious imprecision (wide CIs) and serious indirectness (diversity in outcome measurement). We are uncertain if alternative care models alter hospital admissions for non-specific low back pain at follow-up closest to 12 months compared to usual care as the certainty of evidence was very low (OR 0.86, 95% CI 0.67 to 1.11; I2 = 8%; 12 trials, 10,485 participants). We downgraded the certainty of the evidence by three levels due to serious indirectness (diversity in outcome measurement), serious publication bias (asymmetry of results), minor imprecision (wide CIs), and minor risk of bias (blinding of participants/personnel). High-certainty evidence indicates that alternative care models result in a small but clinically unimportant improvement in pain on a 0 to 10 scale (mean difference -0.24, 95% CI -0.43 to -0.05; I2 = 68%; 36 trials, 9403 participants). Mean pain at follow-up closest to 12 months was 2.4 points on a 0 to 10 rating scale (lower score indicates less pain) with usual care compared to 2.2 points with alternative care models, a difference of 0.2 points better (95% CI 0.4 better to 0.0 better; minimal clinically important difference (MCID) 0.5 to 1.5 points). High-certainty evidence indicates that alternative care models result in a small, clinically unimportant improvement in back-related function compared with usual care (standardised mean difference -0.12, 95% CI -0.20 to -0.04; I2 = 66%; 44 trials, 13,688 participants). Mean back-related function at follow-up closest to 12 months was 6.4 points on a 0 to 24 rating scale (lower score indicates less disability) with usual care compared to 5.7 points with alternative care models, a difference of 0.7 points better (95% CI 1.2 better to 0.2 better; MCID 1.5 to 2.5 points). We are uncertain of the effect of alternative care models on adverse events compared to usual care as the certainty of the evidence was very low (OR 0.81, 95% CI 0.45 to 1.45; I2 = 43%; 10 trials, 2880 participants). We downgraded the certainty of the evidence by three levels due to serious risk of bias (blinding of participants/personnel), serious indirectness (variation in assumed risk), and serious inconsistency (substantial between-study heterogeneity).

AUTHORS' CONCLUSIONS

Compared to usual care, alternative care models for non-specific low back pain probably lead to little or no difference in the quality of care and result in small but clinically unimportant improvements in pain and back-related function. Whether alternative care models result in a difference in total adverse events compared to usual care remains unresolved.

Health care utilization patterns of patients enrolled in an interdisciplinary program for back pain

Background

Chronic low back pain is a costly condition and the leading cause of disability worldwide. A recent call to action identified the overuse of low-value health care as ineffective and potentially harmful in the context of back pain. Interdisciplinary pain programs (IPPs) incorporate physical therapy and behavioral pain treatments with the goal of empowering patients to actively use skills to self-manage pain, decreasing stress, disability, and reliance on low-value care. While IPPs are deemed "cost-effective," few studies elaborate upon the patterns of healthcare utilizations among patients who complete IPPs with attention to valued-based care. The aim of this study was to describe healthcare patterns of patients participating in a interdisciplinary pain program (IPP) for chronic low back pain.

Methods

This observational cohort study describes the healthcare utilization of a group of adult patients (N=143) who participated in an IPP for chronic back pain compared to patients who did not complete the entire program (N=112), and those who were eligible for the program but chose not to participate (N=76). Patterns of healthcare utilization were evaluated in a 12-month period before and after IPP participation. Healthcare utilization categories included outpatient resources, specialist visits, imaging, pain interventional procedures, and acute care utilization. Opioid use was also extracted based on inpatient and outpatient orders, as well as days on opioids within 2 weeks following an emergency department visit or hospitalization. Utilization was defined as a health care visit in which the primary or secondary diagnosis or procedure reason was back pain related. Relative value units (RVUs) measure value used in Medicare reimbursement for physician services.

Results

Overall, healthcare utilization was not markedly different in the 12 months before and after IPP across the 3 groups (graduates, drop-outs, or no participation). However, sub-grouping analyses revealed significant reductions in opioid prescriptions, x-rays, and ED visits in the IPP group for the 12 months after the program, as well as an increased utilization of behavioral pain management.

Conclusions

Adult patients who participated in an IPP for chronic low back pain demonstrated significant reductions in utilization in opioid prescriptions, x-rays and ED visits, while also showing increased participation in active therapies such as behavioral pain management. These findings suggest that participation in a IPP could influence future value-based healthcare decisions, in turn also influencing cost.

Use of General Practitioner Services Among Workers with Work-Related Low Back Pain: A Systematic Review

PURPOSE

Work-related low back pain (WRLBP) is a highly prevalent health problem worldwide leading to work disability and increased healthcare utilisation. General practitioners (GPs) play an important role in the management of WRLBP. Despite this, understanding of GP service use for WRLBP is limited. This systematic review aimed to determine the prevalence, patterns and determinants of GP service use for WRLBP.

METHODS

MEDLINE, Embase via Ovid, Scopus and Web of Science were searched for relevant peer-reviewed articles published in English without any restriction on time of publications. Low back pain (LBP) was considered work-related if the study included workers' compensation claim data analysis, participants with accepted workers' compensation claims or reported a connection with work and LBP. The eligibility criteria for GP service use are met if there is any reported consultation with family practitioner, medical doctor or General Practitioner. Two reviewers screened articles and extracted data independently. Narrative synthesis was conducted.

RESULTS

Seven eligible studies reported prevalence of GP service use among workers with WRLBP ranging from 11% to 99.3%. Only studies from Australia, Canada and the United States met the eligibility criteria. The prevalence of GP service use was higher in Australia (70%) and Canada (99.3%) compared to the United States (25.3% to 39%). The mean (standard deviation) number of GP visits ranged from 2.6 (1.6) to 9.6 (12.4) over a two-year time interval post-WRLBP onset. Determinants of higher GP service use included prior history of low back pain, more severe injury, prior GP visits and younger age.

CONCLUSION

Only seven studies met the eligibility indicating a relative lack of evidence, despite the acknowledged important role that GPs play in the care of workers with low back pain. More research is needed to understand the prevalence, patterns and determinants to support effective service delivery and policy development.

Development and Implementation of MyPainHub, a Web-Based Resource for People With Musculoskeletal Conditions and Their Health Care Professionals: Mixed Methods Study

BACKGROUND

Musculoskeletal conditions, including low back pain (LBP), neck pain, and knee osteoarthritis, are the greatest contributors to years lived with disability worldwide. Resources aiming to aid both patients and health care professionals (HCPs) exist but are poorly implemented and adopted.

OBJECTIVE

We aimed to develop and implement MyPainHub, an evidence-based web-based resource designed to provide comprehensive, credible and accessible information for people with, and HCPs who manage, common musculoskeletal conditions.

METHODS

This mixed methods study adhered to the New South Wales Translational Research Framework and was evaluated against the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Consultation with key stakeholders (patients, HCPs, researchers, industry, consumer groups, and website developers) informed content, design, features, and functionality. Development then aimed to meet the identified need for a "one-stop shop"-a central location for information about common musculoskeletal conditions tailored to a person's condition and risk of poor outcomes. MyPainHub was then developed through an iterative process and implementation strategies were tailored to different health care settings. Quantitative and qualitative evaluation occurred with patients and HCPs.

RESULTS

In total, 127 stakeholders participated in the development phase; initial consultation with them led to embedding 2 validated screening tools (the Short Form Örebro Musculoskeletal Pain Screening Questionnaire and the Keele STarT MSK tool) in MyPainHub to guide information tailoring for patients based on risk of poor outcomes. Development occurred in parallel and feedback from stakeholders informed design and content including structure, functionality, and phrasing and images to use to emphasize key points. Consultation resulted in information for patients being categorized using key guideline-based messages (general information, your pathway, exercise, and imaging) while information for clinicians was categorized into assessment, management, and prognosis. Implementation occurred in different health care settings with the most effective strategies being interactive education via webinars and workshops. The evaluation phase involved web-based questionnaires (patients: n=44; HCPs: n=29) and focus groups (patients: n=6; HCPs: n=6). Patients and HCPs found MyPainHub user-friendly, acceptable, credible, and potentially able to support self-management. Patient participants identified areas for improvement such as including more specific information on preventative measures and pain relief options. Despite positive feedback, only 35% (10/29) of HCPs used MyPainHub with their patients. HCP participants identified challenges including insufficient training and lack of familiarity with using web-based resources in existing clinical workflows. Following implementation, the information contained on MyPainHub changed knowledge and practice for some patients and HCPs.

CONCLUSIONS

Following extensive and iterative stakeholder engagement, MyPainHub was developed as an evidence-based web-based resource and perceived by patients and HCPs as user-friendly, credible, and acceptable. Active implementation strategies are required for adoption and implementation and greater training focusing on strategies to implement MyPainHub into clinical practice may be necessary.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619000871145; https://tinyurl.com/438kkyt3.

Prevalence, causes and outcomes of hospital admissions in Mongolia: a national registry-based descriptive analysis

Background

No systematic data on the prevalence of, reasons for, and outcomes of hospital admissions in Mongolia are currently available.

Methods

In a descriptive analysis, the Mongolian National Hospital Data registry was screened for all hospital admissions in adults from 1 January 2019 to 31 December 2023. The endpoints were the prevalence of and most common reasons for hospital admission, the length of hospital stay, and the hospital mortality rate. Descriptive methods, Chi-square tests, Mann-Whitney-U-tests, and ANOVA on ranks were used for data analysis.

Findings

3,449,083 cases were analysed. The median prevalence of hospital admissions per 100,000 population per year was 20,242 (IQR, 19,412-20,778). The most common main diagnoses were COVID-19 (8.7%; 299,409/3,449,083), chronic tubulo-interstitial nephritis (6.7%; 230,244/3,449,083), chronic arterial hypertension (2.5%; 86,213/3,449,083), chronic ischaemic heart disease (2.3%; 80,071/3,449,083), nerve root/plexus disorders (2.3%; 79,341/3,449,083), hypertensive heart disease (2.1%; 73,597/3,449,083), and lower back pain (1.8%; 60,614/3,449,083). The median length of hospital stay was 7 days (IQR, 6-9) and the hospital mortality rate was 0.66% (22,683/3,449,083). Differences in all endpoints were found between female and male participants, the periods before, during, and after the COVID-19 pandemic, regions of residence, seasons of admission, levels of admission hospitals, and public and private hospitals.

Interpretation

During a five-year period including the COVID-19 pandemic, the prevalence of hospital admissions in Mongolian adults was high during the study period. An analysis of the most common diagnoses leading to hospital admission suggested that many diagnoses could be managed without hospital admission in outpatient or primary care settings.

Funding

Institutional funding (Mongolian National University of Medical Sciences and the Johannes Kepler University).

Guideline concordant care for acute low back pain: A mixed-methods analysis of determinants of implementation

INTRODUCTION

We conducted an explanatory, sequential mixed-methods study to measure variation in the use of imaging and physical therapy (PT) for acute low back pain (LBP) and to identify implementation determinants that might explain variation in use across 22 EDs and 27 urgent cares in urban and rural locations within a community-based health system.

METHODS

We described the patient population and measured concordance with LBP guideline recommendations on imaging and PT referral from January-June 2023. We conducted key informant interviews with physicians and advanced practice providers (APPs), n = 30, from these 49 sites between July - September 2023 and performed content analysis to identify implementation determinants to guideline concordance.

RESULTS

From January-June 30, 2023, 1047 Intermountain Health employed or affiliated physicians and APPs at the 22 adult EDs and 27 adult UCs cared for 8047 patient encounters involving acute LBP with no red flags. 29% of acute LBP patient encounters included an imaging order (ED: 43%; UC: 18%) and 5% included a PT order (ED: 7%; UC: 4%). 17 ED and 13 UC physicians and APPs participated in semi-structured interviews. Their patient encounters represent 6% of the overall study population (ED: 5%; UC: 7%) with order rates and patient population characteristics similar to the full study population. ED and UC clinicians were generally familiar with LBP guideline recommendations but varied significantly in their knowledge and beliefs of the appropriate application of guidelines in evaluation and treatment plans.

DISCUSSION

Guideline concordance for use of imaging and PT varied substantially across physicians and advance practice providers providing care at EDs and UC centers within a community-based health system. Implementation strategies that address barriers identified by this study, including varied understanding of the PT discipline, complex workflows for placing PT referrals, the medico-legal assurance that imaging provides, and the lack of feedback loops in ED and UC centers should be tested in future hybrid implementation-effectiveness trials to increase concordance to LBP guidelines and minimize harm related to overuse of imaging and underuse of conservative first-line treatment approaches.

The PainSMART project: Protocol for a research program on effectiveness, mechanisms of effect and patient-practitioner experiences of the PainSMART-strategy as an adjunct to usual primary care physiotherapy management for musculoskeletal pain

BACKGROUND

Musculoskeletal pain (MSKP) disorders entail a significant burden for individuals and healthcare systems. The PainSMART-strategy has been developed aiming to reduce divergences between patients and healthcare practitioners in their understanding of MSKP by providing a shared basis for communication and to facilitate patients' self-management of MSKP. The objective of the PainSMART-project is to evaluate the effects of the PainSMART-strategy as an adjunct to usual physiotherapy management compared to usual physiotherapy management alone.

METHODS

The PainSMART-project is a research program with a collective suite of studies utilising mixed methods, centred around a randomised controlled trial (ClinicalTrials.gov NCT06187428). Subjects: Adults (18 years or older) seeking primary care for MSKP who are triaged and booked for an initial physiotherapy consultation at five primary care physiotherapy departments within the Swedish public healthcare regions of Östergötland and Jönköping. A total of 490 subjects will be randomised to receive one of two possible interventions.

INTERVENTIONS

Both groups will receive usual physiotherapy management for benign MSKP. The intervention group will also receive the PainSMART-strategy consisting of an educational film, reflection and reinforcement of the film's key messages prior to the initial physiotherapy consultation and a patient-practitioner discussion based on the film.

OUTCOME

The primary outcome is 1) between group mean change over time from baseline to 24 hours post initial physiotherapy consultation and baseline to 3 months regarding self-reported average pain intensity and pain self-efficacy. Secondary outcomes include similar measurements for MSKP illness perception, reassurance of benign nature, pain coping, physical activity, analgesic medication use, sick leave, healthcare use and direct healthcare costs. Physiotherapist and patient reported experience measures and qualitative evaluation of the effects of the PainSMART-strategy on communication at the initial physiotherapy consultation will also be explored.

DISCUSSION

This study will investigate potential added effects of PainSMART-strategy upon usual primary care physiotherapy for MSKP.

Real-world implementation of pain science education and barriers to use in private practice physiotherapy settings: an Australia-wide cross-sectional survey

ABSTRACT

Physiotherapists are critically positioned to integrate education into patient care, including pain science education (PSE) to enhance management and outcomes. Anecdotally, many physiotherapists report difficulty providing PSE in private practice settings. Here, we aimed to explore current PSE use, knowledge, and barriers to implementation. A nationwide online (Qualtrics) survey of PSE-trained Australian private practice physiotherapists assessed use, knowledge (revised Neurophysiology of Pain Questionnaire [rNPQ]), concept application, implementation barriers, and resource awareness/use/preferences, exploring associations with individual/clinic-level factors (clinical experience, PSE training, work location). A total of 278 physiotherapists (62.9% female, 39.4 [11.8] years, 15.2 [11.6] years of experience, 37.2% rural/remote) completed the survey. Pain science knowledge (rNPQ: mean 10.4 [2.2]/13) and perceived PSE competence was high, although 30% supported inaccurate PSE concepts. Pain science education training via professional development course was associated with higher knowledge relative to university training (multivariable; β = 1.337, P < 0.001). Physiotherapists reported providing PSE to 61% of patients, with patient-related barriers (expecting other treatments: 94%; previous negative/contradictory PSE experiences: 89%), clinic-level barriers (time constraints: 77%; insufficient billing schedules: 57%), and clinician-specific barriers (difficulties identifying/addressing patient maladaptive beliefs/behaviours: 53%; cultural/demographic translation challenges: 46%) reported. Fewer years of clinical experience was associated with heightened worry that providing PSE might go wrong (multivariable; β = -0.034, P = 0.010) and/or damage therapeutic relationships (multivariable; β = -0.049, P < 0.001). Physiotherapists were aware of over 100 PSE resources, with varying levels of perceived use/effectiveness, yet were largely unaware of educational strategies. Physiotherapists called for reduced complexity and greater ability to individualise PSE resources. Findings will guide improvements in PSE training/resources, to maximise physiotherapists' confidence and preparedness to effectively implement PSE.

Increasing access to pain care services to improve rural pain management: a realist review investigating factors affecting uptake, implementation, and sustainability

ABSTRACT

Guideline-based care for chronic pain is challenging to deliver in rural settings. Evaluations of programs that increase access to pain care services in rural areas report variable outcomes. We conducted a realist review to gain a deep understanding of how and why such programs may, or may not, work. Our review incorporated interest-holder input in all review phases. We conducted CLUSTER searching to identify literature relevant to understanding the factors affecting the uptake, implementation, and sustainability of programs offering pain care services to rural general practitioners. We used retroductive analysis to generate and test context-mechanism-outcome configurations. Our results are informed by 74 studies. We identified that awareness of the program, provision of necessary resources, and positive attitudes towards the program are required to enable program uptake. When looking for suitable patients to refer, general practitioners need to trust their ability to discuss a referral with a patient in their allocated appointment time. Program sustainability requires clear roles for all providers and sufficient program coordination. Increased access to pain care services enabled interprofessional learning that increased local providers' confidence to manage chronic pain. Many barriers can interfere with successful uptake, implementation, and sustainability of programs that increase access to pain care services in rural settings. It is important to tailor rural workforce programs to local community needs to increase the likelihood of success. Our findings include recommendations for future program planners to consider.

Is low-value care for persistent musculoskeletal pain more common in rural than urban areas? A scoping review

BACKGROUND

Low-value care refers to the provision of health services that confer little or no benefit to patients, or have the potential to incur unwarranted harms. A breadth of literature exists investigating geographical variations in rates of potential low-value interventions for musculoskeletal pain. This scoping review aimed to examine the provision of low-value care for osteoarthritis and lower back pain by degree of rurality (e.g., urban, rural and remote areas).

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) methodology. Electronic searches were performed on five literature databases with no time frame, language or terminology restrictions. Two independent reviewers screened titles and abstracts, reviewed full papers and extracted data from selected studies using a COVIDENCE-developed data extraction tool.

RESULTS

After screening, 21 papers were selected. Two of the papers explicitly referenced low-value care while 19 investigated the provision of potential low-value interventions. Hip and knee arthroplasty, knee arthroscopy, inappropriate pharmacotherapy and complementary and alternative medicine, were more common in rural compared to urban areas. Hip and knee arthroplasty (in women), lumbar spinal fusion, spinal imaging and glucosamine use, were less common in remote compared to regional and urban areas.

CONCLUSIONS

There is a higher report of multiple low-value interventions for osteoarthritis and lower back pain in rural compared to urban areas and lower reporting in remote areas. The lack of healthcare services in rural areas may promote low-value care, while geographical isolation in remote areas may limit utilization of both low- and high-value interventions.

The overlooked burden of persistent physical symptoms: a call for action in European healthcare

Regardless of their cause, persistent physical symptoms are distressing somatic complaints that occur on most days for at least several months. They are common in patients with somatic diseases, functional somatic disorders, mental disorders, and undiagnosed medical conditions and are often associated with significant impairment and medical costs. Despite their prevalence and impact, persistent physical symptoms are often overlooked in medical care. This Personal View stresses the importance of recognising persistent physical symptoms as a European health issue. It advocates improvements in research, clinical management, public health, and policy. Efforts should prioritise integrating models of symptom perception and biopsychosocial perspectives into medical care and education, fostering interdisciplinary collaboration, and developing standardised guidelines to enhance patient care, reduce stigma, and improve clinical outcomes. Increased research funding can accelerate progress in understanding and effectively managing persistent physical symptoms. Addressing these priorities will support patients and healthcare professionals, ensuring adequate care and a higher quality of life for affected individuals.

Clinician experiences in providing reassurance for patients with low back pain in primary care: a qualitative study

QUESTIONS

What reassurance is being delivered by physiotherapists and chiropractors to people with non-specific low back pain? How is it being delivered? What are the barriers and enablers to delivering reassurance to people with non-specific low back pain?

DESIGN

A qualitative study.

PARTICIPANTS

Thirty-two musculoskeletal clinicians (16 physiotherapists and 16 chiropractors) who manage low back pain in primary care.

METHOD

Semi-structured interviews were conducted about their experiences delivering reassurance. The interview schedule was developed using the Theoretical Domains Framework and analysed using framework thematic analysis.

RESULTS

Four themes were identified: giving reassurance is a core clinical skill for delivering high-quality care; it takes practice and experience to confidently deliver reassurance; despite feeling capable and motivated, clinicians identified situations that challenge the delivery of reassurance; and reassurance needs to be contextualised to the individual.

CONCLUSION

Clinicians possess a strong understanding of reassurance but require clinical experience to confidently deliver it. This study provides insights into how reassurance is individualised in clinical practice, including suggestions for clinicians about how to implement reassurance effectively for people with low back pain.

Well-being in pain questionnaire: A novel, reliable, and valid tool for assessment of the personal well-being in individuals with chronic low back pain

BACKGROUND

Well-being is closely related to health, recovery, and longevity. Chronic musculoskeletal pain (CMP) is a major health challenge in the general population, which can have a negative effect on subjective well-being. The ability to identify patients' well-being protective factors, including psychological, social, and lifestyle components, can help guide the therapeutic process in the management of CMP. Recognizing the absence of a dedicated well-being questionnaire, tailored specifically for CMP populations, an 11-item well-being in pain questionnaire (WPQ) was developed.

OBJECTIVES

The objectives were to develop a valid and reliable patient-reported measure of personal pain-specific well-being protective factors and to evaluate its psychometric properties, including (i) internal consistency; (ii) known-group validity between subjects with chronic low back pain (CLBP) and healthy pain-free controls; (iii) convergent validity between the WPQ and measures of health-related quality of life, catastrophizing, sleep quality, symptoms of central sensitization, and anxiety; and (iv) structural validity with exploratory factor analysis.

DESIGN

This is a cross-sectional validation study.

METHODS

After reviewing previous CMP and well-being literature, the novel WPQ items were constructed by expert consensus and target population feedback. The psychometric properties of the WPQ were evaluated in a sample of 145 participants, including 92 subjects with CLBP and 53 pain-free controls.

RESULTS

Feedback from a preliminary group of CMP patients about the relevance, content, and usability of the test items was positive. Internal consistency showed acceptable results (α = 0.89). The assessment of convergent validity showed moderate correlations (≤0.4 or ≥-0.4.) with well-established subject-reported outcome measures. The assessment of structural validity yielded a one-factor solution, supporting the unidimensionality of the WPQ.

CONCLUSIONS

The psychometric results provided evidence of acceptable reliability and validity of the WPQ. Further research is needed to determine the usability of the WPQ as an assessment and outcome tool in the comprehensive management of subjects with CMP.

Factors associated with patients' demand for low-value care: a scoping review

BACKGROUND

Low-value care is unnecessary care that contributes to inefficient use of health resources and constitutes a considerable proportion of healthcare expenditures worldwide. Factors contributing to patients' demand for low-value care have often been overlooked and are dispersed in the literature. Therefore, the current study aimed to systematically summarize factors associated with patients' demand for low-value care.

METHODS

In this scoping review, scientific articles were identified based on a search query conducted in Embase and Scopus. We identified articles using search terms related to low-value care and demand-related factors, published in peer-reviewed journals, and written in English or Dutch. The titles, abstracts, results, and conclusions were inspected to only include articles that were deemed relevant for this topic. From these articles we extracted text fragments that contained factors associated with patients' demand for low-value care. Hereafter, a thematic analysis was applied to openly, axially, and selectively code textual fragments to identify themes within the data.

RESULTS

Forty-seven articles were included in this review. We identified eight core themes associated with patients' demand for low-value care: cognitive biases, emotions, preferences and expectations, knowledge-related factors, socio-cultural factors, biomedical and care-related factors, economic factors, and factors related to the interaction with the healthcare provider. Within these core themes, thirty-three subthemes were identified. For example, risk aversion and anticipated regret aversion are sub-themes of cognitive biases, while consumerism and present and future income effects are sub-themes of economic factors.

CONCLUSIONS

Through this review we provide a systematic overview of factors associated with the demand for low-value care. We found that patients' demand for low-value care could relate to a multitude of factors that were clustered into eight core themes and thirty-three subthemes. To understand the demand for low-value care from the patient's perspective in greater detail, future research should focus on the interaction between and importance of these factors in different care contexts.

Endplate chondrocyte-derived exosomal miR-128-3p mitigates intervertebral disc degeneration by targeting TRAF6 via the miR-128-3p/TRAF6 axis to suppress pyroptosis

Intervertebral disc degeneration (IVDD) is a leading cause of chronic back pain and significantly impacts quality of life. The pathogenesis of IVDD is largely driven by inflammation, pyroptosis, and extracellular matrix (ECM) degradation, which current therapies fail to adequately address. In this study, we explore the therapeutic potential of exosomes derived from endplate chondrocytes (EPCs), with a particular focus on the microRNA miR-128-3p. Our findings reveal that exosomes isolated from third-generation EPCs, enriched with miR-128-3p, exhibit potent anti-inflammatory and anti-pyroptotic effects in lipopolysaccharide-treated nucleus pulposus cells, which are key contributors to IVDD pathology. Specifically, we demonstrate that miR-128-3p delivered via EPC-derived exosomes directly targets TRAF6, effectively suppressing activation of the NF-κB signaling pathway, which is known to play a pivotal role in inflammation and ECM breakdown, leading to a marked reduction in pro-inflammatory cytokine release and mitigation of ECM degradation. Importantly, third-generation EPC exosomes, with higher levels of miR-128-3p, showed superior efficacy compared to fifth-generation EPCs, underscoring the critical role of miR-128-3p in mediating these protective effects. Our research highlights the promise of EPC-derived exosomes, particularly those rich in miR-128-3p, as a novel, cell-free therapeutic approach for IVDD. Unlike current treatments that focus primarily on symptom management, our approach targets key molecular pathways underlying IVDD progression, including inflammation, pyroptosis, and ECM degradation. By elucidating the miR-128-3p/TRAF6 axis, this study provides a foundation for the development of targeted, biologically based interventions aimed at halting or even reversing IVDD, thereby offering hope for more effective and lasting therapeutic options.

Modifiable prognostic factors of high societal costs among people on sick leave due to musculoskeletal disorders: a replication study

BACKGROUND

Musculoskeletal disorders are an extensive burden to society, yet few studies have explored and replicated modifiable prognostic factors associated with high societal costs. This study aimed to replicate previously identified associations between nine modifiable prognostic factors and high societal costs among people on sick leave due to musculoskeletal disorders.

METHODS

Pooled data from a three-arm randomised controlled trial with 6 months of follow-up were used, including 509 participants on sick leave due to musculoskeletal disorders in Norway. Consistent with the identification study, the primary outcome was societal costs dichotomised as high (top 25th percentile) or low. Societal costs included healthcare utilization (primary, secondary, and tertiary care) and productivity loss (absenteeism, work assessment allowance and disability benefits) collected from public records. Binary unadjusted and adjusted logistic regression analyses were used to replicate previously identified associations between each modifiable prognostic factor and having high costs.

RESULTS

Adjusted for selected covariates, a lower degree of return-to-work expectancy was associated with high societal costs in both the identification and replication sample. Depressive symptoms and health literacy showed no prognostic value in both the identification and replication sample. There were inconsistent results with regards to statistical significance across the identification and replication sample for pain severity, self-perceived health, sleep quality, work satisfaction, disability, and long-lasting disorder expectation. Similar results were found when high costs were related to separately healthcare utilization and productivity loss.

CONCLUSION

This study successfully replicated the association between return-to-work expectancy and high societal costs among people on sick leave due to musculoskeletal disorders. Other factors showed no prognostic value or inconsistent results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03871712, 12th of March 2019.

What can I do for my low back pain? The Work In Progress questionnaire!

BACKGROUND

There is growing evidence on Commitment Therapy for people with low back pain (LBP). A self-reported questionnaire is lacking which evaluates commitment by relying on the most recommended actions, the most important core outcome domains, and the most evidenced treatment options.

AIM

To describe the development and psychometric validation of the Work In Progress (WIP) questionnaire.

DESIGN

Development and psychometric validation of the WIP questionnaire in the context of people with LBP, as a means to evaluate Commitment.

SETTING

Outpatient facilities.

POPULATION

People with LBP.

METHODS

The new instrument was created by item generation and selection. Face validity, appropriateness, acceptability and feasibility were investigated. Psychometric testing was carried out in a cross-sectional study and included: 1) exploratory factor analysis; 2) reliability by internal consistency (Cronbach's alpha) and test-retest measurement (Intra-class Correlation Coefficient, ICC2.1); and 3) construct validity by hypothesis testing the correlation of the WIP questionnaire with the Pain Catastrophizing Scale (PCS), the Oswestry Disability Index (ODI), and a pain intensity Numerical Rating Scale (NRS) (Pearson's r correlations).

RESULTS

The WIP questionnaire was successfully developed based on international guidelines and the testing of face validity, appropriateness, acceptability and feasibility were satisfactory. The instrument was administered to 102 people with LBP (39 females, mean age of 49.7±14.6 years [range 20-80], pain median duration of 42.1 weeks [range 3-360]). Factor analysis revealed a two-factor 10-item solution (57% of explained variance). The internal consistency was good (α=0.70-85) and test-retest assessment was excellent (ICC2.1=0.91-94). Construct validity was good, as ≥75% of hypotheses were confirmed.

CONCLUSIONS

The WIP questionnaire is a self-reported tool to evaluate commitment in persons with LBP showing satisfactory psychometric properties. It can be recommended for clinical and research purposes.

CLINICAL REHABILITATION IMPACT

This study adds original new data to the existing knowledge in the field of Commitment within the bio-psychosocial paradigm for disabled people. It is expected to contribute to the evaluative, clinical and rehabilitative approach of individuals with low back pain.

Temporal Trends in the Epidemiology of Lower Back Pain in the United States

STUDY DESIGN

This was an observational study.

OBJECTIVE

This study aims to explore sociodemographic and regional geographic variations in lower back pain (LBP) incidence, prevalence, and burden in the United States (US from 2000 to 2019).

SUMMARY OF BACKGROUND DATA

LBP is a major contributor to lost wages and disability in the United States. As LBP is associated with increasing age and sedentary lifestyle, the incidence of LBP is expected to rise. Due to LBP's multifactorial causes, US epidemiological trends lack sufficient data.

MATERIALS AND METHODS

Descriptive epidemiological data including disability-adjusted life years (DALYs), incidence, and prevalence per 100,000 population from 2000 to 2019 were collected from the Global Burden of Disease database. State-level data regarding poverty, insurance and employment status were obtained from the US Government Census Bureau and US Department of Labor. Statistical significance was indicated by P <0.05.

RESULTS

From 2000 to 2019, the US demonstrated reductions in LBP incidence, prevalence, and DALYs. Regional analysis demonstrated the Midwest to have the greatest mean incidence, prevalence, and DALYs; with Midwestern females significantly more affected than females in other regions. Those aged 25 to 49 in the Midwest were impacted significantly more across all measures compared with age-matched populations in other regions. Nationally, there were no significant associations between unemployment and LBP. Poverty was inversely correlated with LBP incidence. Uninsured status was positively correlated with prevalence and DALYs.

CONCLUSION

Although there has been progress in reducing the impact of LBP in the United States, the Midwest region has greater rates for all measures compared with other US regions. Further, females and those aged 25 to 49 in the Midwest were more likely to be affected by LBP compared with counterparts in other regions. Future studies should identify specific factors contributing to elevated LBP rates in the Midwest in order to guide targeted interventions to reduce the incidence and burden of LBP there.

'A challenge to my professional identity'- resisting the shift from over-management to self-management for back pain within an implementation trial: a qualitative study

OBJECTIVE

The Enhanced Transtheoretical Model Intervention (ETMI) is based on behavioral models and focuses on guiding Chronic Low Back Pain (CLBP) patients to self-manage symptoms and engage in recreational physical activity. While there is promising evidence that ETMI benefits patients, it is unclear how challenging it might be to implement widely. This investigation focused on the perceptions of physiotherapists trained to deliver ETMI for CLBP.

DESIGN

A Qualitative study comprised of semi-structured interviews (July to November 2023). Interviews were audio-recorded, transcribed, coded, and analyzed thematically by two independent researchers.

SETTING

Data were obtained as part of a large implementation study evaluating the uptake and impact of ETMI amongst physiotherapists in a large public healthcare setting.

PARTICIPANTS

22 physiotherapists trained to deliver the ETMI approach and chose to use it with at least one patient.

RESULTS

While physiotherapists acknowledged the evidence base behind ETMI and the clarity of the approach, they struggled to adapt it to routine delivery. Exploration of the reasons for this identified an overarching meta-theme, 'A challenge to my professional identity', and three main themes consisting of 1) interventions such as ETMI contradicted my training. 2) I am ambivalent/ do not accept evidence that contradicts my habitual practice, and 3) I am under-skilled in psychological and communication skills.

CONCLUSION

This study highlights the reluctance of physiotherapists to implement evidence-based interventions such as ETMI, which fundamentally challenge their traditional practice and therapeutic identity. The shift from over-management by experts seeking cures to supporting self-management was not palatable to physiotherapists. The challenge of embracing a new professional identity must be addressed to enable a successful implementation of the approach. CONTRIBUTION OF THE PAPER.

A scoping review on implementation processes and outcomes of models of care for low back pain in primary healthcare

BACKGROUND

To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare.

METHODS

MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches.

RESULTS

Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes.

CONCLUSIONS

The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare.

REGISTRATION

Open Science Framework Registries ( https://osf.io/rsd8x ).

Promoting multidisciplinary pain management in low- and middle-income countries-challenges and achievements

ABSTRACT

The burden of pain in low- and middle income countries (LMICs) is high and expected to rise further with their ageing populations. Multidisciplinary pain management approaches based on the biopsychosocial model of pain have been shown to be effective in reducing pain-related distress and disability, but these approaches are still lacking in many LMICs due to various factors, including low levels of awareness about the role of multidisciplinary pain clinics, lack of prioritisation for pain services, and lack of healthcare professionals trained in pain management. The International Association for the Study of Pain (IASP) has several educational programs to promote multidisciplinary pain management in LMICs, in the form of education grants, pain fellowships, pain camps and, most recently, the development of a Multidisciplinary Pain Centre Toolkit. This article describes the various educational programs, focusing on Southeast Asia, that demonstrate how targeted educational programs which include skills training, follow-up and mentorship, can translate into the formation of new multidisciplinary pain management services in settings with limited resources.

Spinal pain prevalence and associated determinants: A population-based study using the National Survey for Wales

Spinal pain (SP) remains the leading cause of disability worldwide. The present study aimed to establish a current prevalence of SP and associated determinants in Wales by retrospectively analyzing data from the National Survey for Wales Dataset (NSWD). The NSWD is a large-scale cross-sectional, representative sample of adults across Wales, UK. A univariable and multivariable regression analysis was carried out on self-reported answers to health and well-being questions contained within the NSWD (2016-2020) to determine the strength of association of various determinants and comorbidities related to spinal pain. A total population of 38,954 of adults were included in the analysis. The study population included interview responses of 21,735 females and 17,219 males. The prevalence of SP in Wales was 4.95% (95% CI: 4.74%-5.15%) with a total of 847 males (4.92%, CI: 4.60%-5.24%) and 1082 females (4.98%, CI: 4.69%-5.27%) reporting spinal pain. The age group with the highest prevalence of SP was in the 70+ years age group for both males (5.44%, CI: 4.82%-6.07%) and females (5.95%, CI: 5.37%-6.54%). The strength of association between age and SP reaches its peak at 50-59 years with an adjusted Odds Ratio (aOR) of 3.74 (p = <0.001), that decreases slightly at 60-69 years and 70+ years. For various comorbidities included in the NSWD, significant associations with SP were confirmed for: mental illness (aOR = 1.42, p = <0.001), migraine (aOR = 2.73, p = <0.001), nervous system issues (aOR = 1.61, p = <0.001), arthritis (aOR = 1.30, p = <0.001) and issues with bones/joints/muscles (aOR = 1.93, p = <0.001). For lifestyle factors, associations were confirmed for current smokers (aOR = 1.41, p = <0.001) and ex-smokers (aOR = 1.23, p = 0.003). This study demonstrates a low prevalence of SP in Wales when compared to global estimates and strong associations to a variety of determinants. This still represents a significant societal burden and these findings may help inform public health initiatives to encourage prevention and evidence-based interventional strategies and ultimately, improve the quality of life for those suffering with SP in Wales.

The methodological quality of clinical trials of physical therapy for low back pain varies between countries with different income levels. A meta-epidemiological study

BACKGROUND

Low back pain is a severe global health problem. To face this issue, testing interventions using rigorously performed randomized controlled trials is essential. However, it is unclear if a country's income level is related to the quality of trials conducted.

OBJECTIVE

To compare the frequency and methodological quality of randomized controlled trials of physical therapy interventions for low back pain conducted in countries with different income levels.

METHODS

This meta-epidemiological study retrieved trials from the Physiotherapy Evidence Database (PEDro), Literatura Latino Americana em Ciências da Saúde (LILACS), and Scientific Electronic Library Online (SciELO). The methodological quality was evaluated using the 0-10 PEDro scale. Then we calculated the mean differences with a 95% confidence interval and performed an ANOVA test with Bonferroni correction to compare the PEDro scores between income groups.

RESULTS

We included 2552 trials; 70.4% were conducted in high-income countries. The mean (standard deviation) PEDro score of all trials was 5.5 (0.03) out of 10. Trials from low- or lower-middle-income countries had lower methodological quality than those from upper-middle- and high-income countries, but the mean difference was small (-0.6 points (95% CI -0.9, -0.3), and -0.7 points (95% CI -1.1, -0.5) respectively).

CONCLUSION

Income level influences the methodological quality of trials of physical therapy intervention but is not the only factor. Implementing strategies to improve the methodological rigor of trials in patients with low back pain is necessary in all countries, regardless of income level.

Assessing the knowledge of low back pain among physiotherapists in Spain: A cohort study with pre- and post-educational course evaluation

BACKGROUND

Low back pain (LBP) is the most prevalent musculoskeletal disorder worldwide and physiotherapists are among the primary healthcare professionals assessing and treating the condition. However, scientific knowledge regarding the management of LBP amongst physiotherapists is largely unknown.

OBJECTIVES

To evaluate the level of evidence-based knowledge among Spanish physiotherapists in LBP management and assess knowledge enhancement following the completion of an e-learning course.

DESIGN

Single-arm cohort study with pre-post evaluation.

METHODS

This single-arm pre-post study involved 1350 physiotherapists practicing in Spain. Initially, participants underwent a 22-question test on evidence-based LBP knowledge, covering socio-economic impact, characteristics of LBP, rehabilitation goals, psychosocial factors, and high- and low-value interventions. After completing the course, participants took a final test with the same 22 questions in randomized order.

RESULTS

Out of the 1350 physiotherapists enrolled, 857 completed the course. The initial responses demonstrated that almost half of the participants considered medical imaging essential before starting physiotherapy treatment, perceived glucocorticoids as recommended for chronic low back pain, and considered ergonomic adjustments crucial for managing the condition. Individuals who completed their education more than 10 years ago showed a minor improvement in evidence-based knowledge compared to those who recently finished their university degree. Following the course, participants displayed improved knowledge, narrowing prior disparities in error percentages across questions.

CONCLUSION

Due to existing gaps in physiotherapists' evidence-based knowledge of LBP, particularly among those who have worked longer time as physiotherapists, e-learning initiatives may be a feasible approach to support continuous training of physiotherapists.

Key Factors Driving Physiotherapy Use in Patients with Nonspecific Low Back Pain: Retrospective Clinical Data Analysis

Background/objectives: Understanding the factors that influence physiotherapy (PT) service use among patients with nonspecific lower back pain (LBP) is necessary to optimize treatment strategies, healthcare resource allocation, and the planning of value-based initiatives. We report factors that influence the number of PT visits per episode of care (defined as a referral from a physician) for an LBP population in Saudi Arabia, and compare them with patients experiencing their first and recurrent episodes of LBP. Methods: LBP patients were retrospectively enrolled from a clinical dataset derived from an outpatient PT clinic in Saudi Arabia. The primary outcome variable was the number of PT visits performed per episode of care. Multiple linear regression analysis was performed to examine the relationships between the numbers of PT visits per episode of care and independent variables. Results: The number of PT sessions per week (β 0.34, p < 0.001), compliance with PT sessions (β 0.31, p < 0.001), and pre-pain scores (β 0.29, p < 0.001) explained 41.8% (adjusted R2 0.32) of the variance in the total number of PT visits per episode of care (p < 0.001). Conclusions: Factors that might improve value-based care for LBP patients are reported. The more PT sessions per week, compliance with these sessions, and higher baseline pain scores predict a higher number of PT visits per episode of care among these patients. While reported for a Saudi Arabian population, there is no reason to believe that these findings do not apply internationally.

Duration, Cost, and Escalation of Care Events for Physical Therapy Management of Low Back Pain in Service Members With Limb Loss

INTRODUCTION

Physical therapy (PT) is recommended as a primary treatment for low back pain (LBP), a common and impactful musculoskeletal condition after limb loss. The purpose of this brief report is to report the duration and cost of PT care, and subsequent escalation of care events, for LBP in service members with and without limb loss.

MATERIALS AND METHODS

This was a retrospective cohort, descriptive study. Service members with and without limb loss (matched) who received PT for LBP at a military treatment facility from 2015 to 2017 were included. Duration of PT care, number of PT visits, and escalation of care events 1 year after PT were extracted from medical records. Escalation of care events was identified as epidural steroid injections, referrals to specialists (e.g., orthopedists, spine surgeons, and pain management), and LBP-related hospitalizations.LBP-related PT encounters were queried; duration of care, number of visits, and cost of care were quantified. Escalation of care events, including opioid prescription, epidural steroid injections, specialty referrals, and hospitalizations, were identified up to 1 year after PT care.

RESULTS

The average course of PT care for LBP was 12.9 more visits, 48.7 days longer, and $764.50 more expensive in service members with limb loss (n = 16) vs. those without limb loss (n = 48). Higher rates of opioid prescriptions and specialty referrals were observed in service members with limb loss.

CONCLUSIONS

This study suggests that service members with limb loss and LBP received higher quantities and longer durations of PT than those without limb loss, yielding a nearly 4 times higher cost of PT.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Physiotherapist- and patient-reported barriers to guideline implementation of active physiotherapeutic management of low back pain: A theory-informed qualitative study

BACKGROUND AND OBJECTIVE

Adoption of low back pain (LBP) guidelines in physiotherapeutic management is a well-documented problem. Thereby, an in-depth understanding of the barriers to implement an active approach for both patients and physiotherapists is needed.

DESIGN

Semi-structured interviews were conducted with physiotherapists and patients with non-specific LBP. Interviews, guided by the Theoretical Domains Framework (TDF), were analyzed using the Qualitative Analysis Guide of Leuven.

RESULTS

A total of 20 participants were interviewed, including ten physiotherapists and ten patients. Our findings reveal that patients and physiotherapists face each 23 barriers spanning 14 TDF domains. The TDF domain "social influences" revealed the most barriers, followed by "beliefs about consequences" and "environmental context" for patients and physiotherapists, respectively. Five barriers did overlap between both groups (lack of guideline awareness, incorrect exercise performance, interdisciplinary communication gaps, time constraints and challenges in patient compliance).

CONCLUSIONS

Barriers to LBP guideline recommended physiotherapeutic practices span all 14 TDF domains. Consequently, future implementation interventions need to address multiple TDF domains for effective LBP guideline implementation.

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.

Breaking the cycle of reoccurring low back pain with integrated motivational interviewing and cognitive behavioural therapy to facilitate education and exercise advice: a superiority randomised controlled trial study protocol

BACKGROUND

Non-specific low back pain is a common and costly global issue. Many people with low back pain live for years with ongoing symptom recurrence and disability, making it crucial to find effective prevention strategies. Motivational interviewing (MI) is an evidence-based patient-centred counselling style that helps motivate individuals to change their behaviours. In combination, MI and cognitive-behavioural therapy (MI-CBT) has the potential to yield long term improvements in pain and disability and reduce incidence of recurrence.

METHOD

This is a two-arm superiority randomised controlled trial comparing MI-CBT and Education (n = 83) with Education only (n = 83). Participants that have recovered from a recent episode of non-specific low back pain (7th consecutive day with pain ≤ 2 on a 0-10 numeric pain rating scale) will be eligible for inclusion into the study. Both groups will receive five 30-min sessions over a 10-week period as well as the Navigating Pain booklet, homework book and a standardised exercise programme. In the intervention group, MI-CBT techniques will be used to provide individualised support, identify beliefs, and increase engagement with the resources provided. Outcomes measures include pain (current and in the last 7 days) as rated on the numeric pain rating scale. This will be used to determine recurrence (number of participants who report back pain ≥ 3 out of 10 on the numeric pain rating scale). Furthermore, self-reported (1) pain intensity; (2) pain catastrophizing; (3) fear-avoidance beliefs; (4) pain self-efficacy; (5) depression and anxiety; (6) disability will be measured. All outcomes will be measured at baseline, and again at 3-, 6-, and 12-months post allocation.

DISCUSSION

The effective delivery of self-management strategies to prevent recurrence of low back pain is an important aspect that requires urgent attention. This study will provide new information on the effectiveness of using an MI-CBT approach to facilitate self-management through education and exercise to improve low back pain outcomes. Evidence emerging from this trial has the potential to inform clinical practice and healthcare management of non-specific low back pain.

TRIAL REGISTRATION

Prospectively registered with Australian New Zealand Clinical Trials Registry: ACTRN12623000746639 (10/07/2023).

Biomechanical properties of the human superficial fascia: Site-specific variability and anisotropy of abdominal and thoracic regions

Superficial fascia is a fibrofatty tissue found throughout the body. Initially described in relation to hernias, it has only recently received attention from the scientific community due to new evidence on its role in force transmission and structural integrity of the body. Considering initial difficulties in its anatomical identification, to date, a characterization of the superficial fascia through mechanical tests is still lacking. The mechanical properties of human superficial fasciae of abdominal and thoracic districts (back) of different subjects (n = 4) were then investigated, focusing on anisotropy and viscoelasticity. Experimental tests were performed on samples taken in two perpendicular directions according to body planes (cranio-caudal and latero-medial axes). Data collected from two different uniaxial tensile protocols, failure (i.e., ultimate tensile strength and strain at break, Young's modulus and toughness) and stress-relaxation (i.e., residual stress), were processed and then grouped for statistical analysis. Failure tests confirmed tissue anisotropy, revealing the stiffer nature of the latero-medial direction compared to the cranio-caudal one, for both the districts (with a ratio of the respective Young's moduli close to 2). Furthermore, the thoracic region exhibited significantly greater strength and resultant Young's modulus compared to the abdomen (with greater results along the latero-medial direction, such as 6.13 ± 3.11 MPa versus 0.85 ± 0.39 MPa and 24.87 ± 15.23 MPa versus 3.19 ± 1.62 MPa, respectively). On the contrary, both regions displayed similar strain at break (varying between 38 and 47%), with no clear dependence from the loading directions. Stress-relaxation tests highlighted the viscous behavior of the superficial fascia, with no significant differences in the stress decay between directions and districts (35-38% of residual stress after 300 s). All these collected results represent the starting point for a more in-depth knowledge of the mechanical characterization of the superficial fascia, which can have direct implications in the design, implementation, and effectiveness of site-specific treatments.

Physical functioning in the lumbar spinal surgery population: A systematic review and narrative synthesis of outcome measures and measurement properties of the physical measures

BACKGROUND

International agreement supports physical functioning as a key domain to measure interventions effectiveness for low back pain. Patient reported outcome measures (PROMs) are commonly used in the lumbar spinal surgery population but physical functioning is multidimensional and necessitates evaluation also with physical measures.

OBJECTIVE

1) To identify outcome measures (PROMs and physical) used to evaluate physical functioning in the lumbar spinal surgery population. 2) To assess measurement properties and describe the feasibility and interpretability of physical measures of physical functioning in this population.

STUDY DESIGN

Two-staged systematic review and narrative synthesis.

METHODS

This systematic review was conducted according to a registered and published protocol. Two stages of searching were conducted in MEDLINE, EMBASE, Health & Psychosocial Instruments, CINAHL, Web of Science, PEDro and ProQuest Dissertations & Theses. Stage one included studies to identify physical functioning outcome measures (PROMs and physical) in the lumbar spinal surgery population. Stage two (inception to 10 July 2023) included studies assessing measurement properties of stage one physical measures. Two independent reviewers determined study eligibility, extracted data and assessed risk of bias (RoB) according to COSMIN guidelines. Measurement properties were rated according to COSMIN criteria. Level of evidence was determined using a modified GRADE approach.

RESULTS

Stage one included 1,101 reports using PROMs (n = 70 established in literature, n = 67 developed by study authors) and physical measures (n = 134). Stage two included 43 articles assessing measurement properties of 34 physical measures. Moderate-level evidence supported sufficient responsiveness of 1-minute stair climb and 50-foot walk tests, insufficient responsiveness of 5-minute walk and sufficient reliability of distance walked during the 6-minute walk. Very low/low-level evidence limits further understanding.

CONCLUSIONS

Many physical measures of physical functioning are used in lumbar spinal surgery populations. Few have investigations of measurement properties. Strongest evidence supports responsiveness of 1-minute stair climb and 50-foot walk tests and reliability of distance walked during the 6-minute walk. Further recommendations cannot be made because of very low/low-level evidence. Results highlight promise for a range of measures, but prospective, low RoB studies are required.

Public Perceptions on the Use of the Physical Activity Readiness Questionnaire

Self-administered pre-participation screening for physical activity (PA) requires an instrument that should be easily used and identify individuals at high risk. The Physical Activity Readiness Questionnaire (PAR-Q+) has been used for many years. Its ease of use and ability to identify those not fit to undergo PA has not been assessed. This study was to determine the rates of the PAR-Q+ in identifying adults who may not be fit for moderate or intense PA and obtain feedback on the use of this tool. A randomized, cross-sectional study involving a wide spectrum of members of the public was carried out. Participants were asked to provide their bio-characteristics, complete the PARQ+, and provide feedback on the questionnaire. With 1019 participants, about 33.1% of the participants using the PARQ+ would have required further medical evaluation. Except for those patients with respiratory illness, there was no difference in levels of PA in those who answered yes or no to the seven PARQ+ questions. Only 4 of the 7 main PAR-Q+ questions were perceived by the public as easily understood. Difficulties were encountered with 21 of the 45 follow-up questions, especially amongst those with co-morbidities. The wordiness of the questions and the large number of technical terms were also sources of concern. Suggestions were provided by participants on areas where improvements may be made to the wording of the questions. The study suggests that the PAR-Q+ probably over-identified those who require further medical evaluation. In addition, the wordiness of the questions and frequent use of medical jargon made the PARQ+ challenging to understand and use. The suggestions provide opportunities to review areas for possible improvements.

Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023

INTRODUCTION

Low back pain is a common reason for presentation to the Emergency Department (ED). However, there are limited large-scale, recent data on the epidemiology, disposition, and medication administration for this condition. The objective of this was to assess the incidence, admission rates, medication administrations, and discharge prescriptions among ED visits for low back pain in the United States.

METHODS

This was a cross-sectional study of ED presentations for low back pain from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits for adults with low back pain identified by ICD-10 codes were included. Outcomes included admission rates, distribution of opioid, benzodiazepine, (non-benzodiazepine) muscle relaxant, acetaminophen, NSAID, and corticosteroid medications administered in the ED, and distribution of opioid, benzodiazepine, muscle relaxant, and corticosteroid medications given upon discharge. Subgroup analyses were performed by specific medication.

RESULTS

Of 207,154,419 ED encounters, 12,241,240 (5.9%) were due to back pain with 1,957,299 of these (16.0%) admitted. The admission rate increased over time from 12.8% to 17.1%. The most common medication given in the ED was opioids (40.7%), followed by acetaminophen (37.8%), NSAIDs (22.6%), muscle relaxants (18.4%) benzodiazepines (12.8%), and corticosteroids (5.5%). The most common medications prescribed upon discharge were muscle relaxants (32.1%), followed by opioids (23.2%), corticosteroids (12.2%), and benzodiazepines (3.0%).

CONCLUSION

Low back pain represents a common reason for presentation to the ED, and admissions have been increasing over time. Opioids remain the most common ED medication, whereas muscle relaxants have arisen as the most common discharge prescription. These findings can help inform health policy decisions, resource allocation, and evidence-based interventions for medication administration.

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

Chronic primary low back pain (CPLBP) refers to low back pain that persists over 3 months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective in relieving CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n = 49) or a control intervention (n = 49), 12 times over 4 weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in 4 body regions, pain catastrophizing, Central Sensitization Inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (P < .001) and higher scores for all questionnaires (P < .001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% confidence interval, -11.0 to -12.5], P = .01), but not disability (P = .5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (P < .05). Pain catastrophizing was reduced after SMT compared with the control intervention (P < .05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE: This randomized controlled trial found that 12 sessions of SMT yield greater relief of CPLBP than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.

The association of physical activity and sedentary behaviour with low back pain disability trajectories: A prospective cohort study

BACKGROUND

Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of risk factors might contribute to a better understanding of the course of LBP.

OBJECTIVES

To investigate the association of habitual physical activity (PA) and sedentary behaviour (SB), measured at baseline, with disability trajectories in adults with LBP.

METHODS

A prospective cohort study where habitual PA levels were measured using the Short QUestionnaire to ASsess Health enhancing physical activity (SQUASH), SB was calculated as average sedentary hours per day, and LBP disability using the Oswestry Disability Index (ODI). Participants completed the questionnaires at one and a half, three, six, and twelve months. Linear mixed models were estimated to describe the association of habitual PA levels SB measured at baseline with disability trajectories. Other predictors were gender, education level, age, pain, number of previous episodes of LBP, and duration of LBP.

RESULTS

Habitual SB measured at baseline in adults (n = 347) with LBP were not associated with disability trajectories. For PA, participants with one metabolic equivalent of task (MET) hour per day above average recovered 0.04 [95% CI 0.004 to 0.076] points on the ODI per month faster than participants with an average amount of MET hours per day.

CONCLUSIONS

Habitual SB was not associated with LBP disability trajectories over a one-year follow-up. High levels of habitual PA at baseline were associated with improved recovery in LBP disability trajectory, but the finding is not clinically relevant.

Unlocking Patient Voices: Advancing Physical Therapist Practice With Discrete Choice Experiments

As health care moves away from volume-based to value-based delivery, the role of the patient in determining value in health care is now paramount. Thus, health care should be aligned with what matters most to patients. Ascertaining patient preferences is therefore critical if we are to provide patients with care that is meaningful to them. However, preferences are difficult to measure and traditional methods of preference measurement in physical therapy face challenges when attempting to measure such. This perspective makes a case for greater use of the discrete choice experiment (DCE) in physical therapy as a research method to measure patient preferences. The DCE is a research method used to elicit preferences for services or goods. This article addresses the importance of eliciting patient preferences as part of person-centered care in the value-based space, the challenges faced in preference measurement in physical therapy, and how the DCE can alleviate some of those challenges. It also provides examples of the DCE in health care and suggests ways in which it can be effectively used in physical therapist practice to improve the delivery of meaningful rehabilitation services to patients. Implementing greater use of the DCE in physical therapy can improve person-centered physical therapist service delivery and inform policy development that creates cost-effective care which is meaningful to patients. It can further help to highlight the value of physical therapy to population health, and to policy makers as health care moves toward more value-based models.

Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction

BACKGROUND

Adults with refractory, mechanical chronic low back pain associated with impaired neuromuscular control of the lumbar multifidus muscle have few treatment options that provide long-term clinical benefit. This study hypothesized that restorative neurostimulation, a rehabilitative treatment that activates the lumbar multifidus muscles to overcome underlying dysfunction, is safe and provides relevant and durable clinical benefit to patients with this specific etiology.

MATERIALS AND METHODS

In this prospective five-year longitudinal follow-up of the ReActiv8-B pivotal trial, participants (N = 204) had activity-limiting, moderate-to-severe, refractory, mechanical chronic low back pain, a positive prone instability test result indicating impaired multifidus muscle control, and no indications for spine surgery. Low back pain intensity (10-cm visual analog scale [VAS]), disability (Oswestry Disability Index), and quality of life (EuroQol's "EQ-5D-5L" index) were compared with baseline and following the intent-to-treat principle, with a supporting mixed-effects model for repeated measures that accounted for missing data.

RESULTS

At five years (n = 126), low back pain VAS had improved from 7.3 to 2.4 cm (-4.9; 95% CI, -5.3 to -4.5 cm; p < 0.0001), and 71.8% of participants had a reduction of ≥50%. The Oswestry Disability Index improved from 39.1 to 16.5 (-22.7; 95% CI, -25.4 to -20.8; p < 0.0001), and 61.1% of participants had reduction of ≥20 points. The EQ-5D-5L index improved from 0.585 to 0.807 (0.231; 95% CI, 0.195-0.267; p < 0.0001). Although the mixed-effects model attenuated completed-case results, conclusions and statistical significance were maintained. Of 52 subjects who were on opioids at baseline and had a five-year visit, 46% discontinued, and 23% decreased intake. The safety profile compared favorably with neurostimulator treatments for other types of back pain. No lead migrations were observed.

CONCLUSION

Over a five-year period, restorative neurostimulation provided clinically substantial and durable benefits with a favorable safety profile in patients with refractory chronic low back pain associated with multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02577354; registration date: October 15, 2016; principal investigator: Christopher Gilligan, MD, Brigham and Women's Hospital, Boston, MA, USA. The study was conducted in Australia (Broadmeadow, New South Wales; Noosa Heads, Queensland; Welland, South Australia; Clayton, Victoria), Belgium (Sint-Niklaas; Wilrijk), The Netherlands (Rotterdam), UK (Leeds, London, Middlesbrough), and USA (La Jolla, CA; Santa Monica, CA; Aurora, CO; Carmel, IN; Indianapolis, IN; Kansas City, KS; Boston, MA; Royal Oak, MI; Durham, NC; Winston-Salem, NC; Cleveland, OH; Providence, RI; Spartanburg, SC; Spokane, WA; Charleston, WV).

Factors influencing imaging clinical decision-making in low back pain management. A scoping review

BACKGROUND

The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process.

AIM

Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management.

DESIGN

Scoping review.

METHOD

This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories.

RESULTS

After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors.

CONCLUSIONS

The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.

It's OK to Move! Effect of a Brief Video on Community Confidence in Activity Despite Back Pain: A Randomized Trial

OBJECTIVE: To estimate the difference in confidence to become active despite low back pain in people who were exposed to one of 2 video interventions delivered on social media, compared to no intervention. DESIGN: A proof-of-concept, 3-group randomized controlled trial, in a 1:1:1 ratio. METHODS: Participants aged 18 years and over, with and without low back pain, were recruited via the social media channel Facebook, to view either a humorous video, a neutral video, or to no intervention. The videos were delivered online, explained evidence-based management for low back pain, and were designed to "go viral." The primary outcome was confidence in becoming active despite pain, measured using the Pain Self Efficacy Questionnaire (Item 10) (ranges from 0 [not at all confident] to 6 [completely confident]) immediately after watching the video. We aimed to capture the real-time impact and immediate reactions that contributed to the content's reach. RESULTS: Among 1933 randomized participants (mean [standard deviation] age: 58.9 [14.0] years, 1285 [75%] women), 1232 [70%] had low back pain and 88.8% completed the primary outcome. One thousand two hundred sixty-four participants were randomized to receive a video intervention, and 633 participants did not receive a video. On a 6-point scale, individuals exposed to either video (n = 1088) showed a mean confidence level 0.3 points higher (95% confidence interval: 0.1, 0.6) compared with no video (n = 630). CONCLUSION: Participants who viewed a brief video intervention reported a very small difference in confidence to become active despite low back pain, compared with no intervention. The difference may lack clinical relevance. J Orthop Sports Phys Ther 2024;54(6):1-8. Epub 18 April 2024. doi:10.2519/jospt.2024.12412.