Low back pain: it is time to embrace complexity

Dysmenorrhea and the clinical encounter: testing a conceptual model of physician-patient interactions among emerging adults

ABSTRACT

Dysmenorrhea affects as much as 85% of female youth in Canada and the United States and can negatively impact academic performance, overall health, and mental well-being. The physician-patient relationship can play an important role in supporting patients with pain conditions, such as dysmenorrhea. Through effective communication, trust, and validation, physician-patient interactions can empower pain patients, potentially improving pain outcomes. To date, no studies have quantitatively examined the impact of physician-patient interactions on youth's experiences of dysmenorrhea. Therefore, our aim was to explore the relationships among perceived physician communication, pain invalidation, trust in the physician, treatment adherence, menstrual sensitivity, and dysmenorrhea symptom severity among emerging adults (EA) and test a conceptual model of potential interactions using partial least squares structural equation modeling (PLS-SEM). The online survey was administered to Canadian and American EA aged 18 to 21 (Mage = 19.4, SD = 1.1) years with dysmenorrhea. Two models were tested using PLS-SEM: model A only included participants who had received a treatment plan from their physician (n = 279) and model B included the full data set (N = 362). In both models, the perception of more effective physician communication and reduced pain invalidation were related to lower dysmenorrhea symptom severity through menstrual sensitivity. In model A, better physician communication and lower pain invalidation were also associated with higher reported treatment adherence by trust in the physician; however, neither treatment adherence nor trust in the physician were associated with dysmenorrhea symptom severity. Future research should include additional elements within the clinical encounter and further refine the model.

Low Back Pain Disparities in Portugal: A Population-Based Study Analysing the Role of Social Determinants of Health

INTRODUCTION

Despite growing research, the relationship between social determinants of health (SDoH) and low back pain (LBP) remains inconsistent. This study aimed to investigate the associations between SDoH and self-reported LBP in the Portuguese population in 2019 and explore potential differences between rural and urban areas.

METHODS

This is a cross-sectional study that includes 13,230 participants from the 2019 Portuguese National Health Interview Survey. Multivariable logistic regression models were used to assess the associations between SDoH and LBP. Interaction effects were examined to determine whether these relationships are modified by the degree of urbanisation/rurality.

RESULTS

The regression model for demographic and economic determinants showed associations between LBP and sex, age, marital status, education and financial capacity, with older rural residents having a higher likelihood of reporting LBP. The psychosocial model revealed that poor health status, sleep disturbances, fatigue, and dissatisfaction with life course were positively associated with LBP. In the behavioural model, obesity and history of smoking increased the probability of reporting LBP, whereas exercise behaviours reduced it and significantly varied across urban and rural regions. Health-system factors, including hospital visits, medication use, consultations with rehabilitation professionals, delayed healthcare access, and unmet health needs due to financial constraints, were associated with LBP. Rural residents were more likely to seek outpatient care at hospitals.

DISCUSSION

These findings emphasise the importance of integrating the evaluation of SDoH into healthcare settings to develop tailored interventions for LBP management.

CONCLUSION

LBP was influenced by several SDoH, but differences between rural and urban areas were limited.

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 ).

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Perceived factors influencing the success of pain neuroscience education in chronic musculoskeletal pain: a meta-synthesis of qualitative studies

PURPOSE

We aimed to identify the factors influencing the success of Pain Neuroscience Education (PNE) in chronic musculoskeletal (MSK) pain from the perspective of those experiencing PNE first-hand.

MATERIALS AND METHODS

We conducted a meta-synthesis of qualitative studies. Articles were found on MEDLINE via Pubmed, EMBASE, Cochrane Library, CINHAL, and PsycINFO up to April 2023. Eligible qualitative studies focussed on adults (>16 years old) with a diagnosis of chronic primary or secondary MSK pain who performed PNE. Thematic synthesis by Thomas and Harden was followed. The Critical Appraisal Skills Programme (CASP) tool ensured the quality of the studies, while the Confidence in Evidence from the Reviews of Qualitative Research (CERQual) approach facilitated data confidence assessment.

RESULTS

Nine studies were included (188 participants). Three analytical themes were developed: (i) "Efficient Communication of Information", emphasising the importance of accurate content transmission; (ii) "Emotional Support and Well-being", recognising emotional aspects as integral to treatment; and (iii) "Empowerment Promotion", focusing on information retention and personal transformation. The studies showed good quality, with moderate confidence in the evidence.

CONCLUSIONS

The perceived factors influencing the success of PNE are intricately related to the domain of communication, the emotional dimension of personal experience, and the capacity to be empowered.

Effectiveness of a pain neuroscience education programme on the physical activity of patients with chronic low back pain compared with a standard back school programme: protocol for a randomised controlled study (END-LC)

INTRODUCTION

Education is recognised as an effective and necessary approach in chronic low back pain. Nevertheless, data regarding the effectiveness of education in promoting physical activity in the medium term or long term are still limited, as are the factors that could lead to successful outcomes. Our study aims to assess the effectiveness of a pain neuroscience education programme compared with traditional back school on physical activity 3 months and 1 year after educational sessions coupled with a multidisciplinary rehabilitation programme. Additionally, we seek to evaluate the effects of these educational interventions on various factors, including pain intensity and psychobehavioural factors. Finally, our goal is to identify the determinants of success in educational sessions combined with the rehabilitation programme.

METHODS AND ANALYSIS

The study will involve 82 adults with chronic low back pain. It will be a monocentric, open, controlled, randomised, superiority trial with two parallel arms: an experimental group, 'pain neuroscience education', and a control group, 'back school'. The primary outcome is the average number of steps taken at home over a week, measured by an actigraph. Secondary outcomes include behavioural assessments. Descriptive and inferential analysis will be conducted. Multivariate modelling will be performed using actimetric data and data from the primary and secondary outcomes.

ETHICS AND DISSEMINATION

The Committee for Personal Protection of Ile de France VII (CPP) gave a favourable opinion on 22 June 2023 (National number: 2023-A00346-39). The study was previously registered with the National Agency for the Safety of Medicines and Health Products (IDRCB: 2023-A00346-39). Participants signed an informed consent during the inclusion visit. This protocol is the version submitted to the CPP entitled 'Protocol Version N°1 of 03/29/2023'. The results of the study will be presented nationally and internationally through conferences and publications.

TRIAL REGISTRATION NUMBER

NCT05840302.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Personalized assessment and management of non-specific low back pain

BACKGROUND AND OBJECTIVE

Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients.

DATABASES AND DATA TREATMENT

Narrative review.

RESULTS

NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively.

CONCLUSIONS

The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient.

SIGNIFICANCE STATEMENT

Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.

Systemic pro- and anti-inflammatory profiles in acute non-specific low back pain: An exploratory longitudinal study of the relationship to six-month outcome

OBJECTIVES

Pro-inflammatory molecules are thought to underpin the development of chronic low back pain (LBP). Although research has begun to explore the association between pro-inflammatory molecules in acute LBP and long-term outcome, no study has explored the role of anti-inflammatory molecules. We aimed to explore whether levels of systemic pro- and anti-inflammatory molecules 1) changed over a period of six months from the onset of acute LBP; 2) differed between people who were recovered (N = 11) and unrecovered (N = 24) from their episode of LBP at six months; 3) baseline psychological factors were related to inflammatory molecule serum concentrations at baseline, three and six months.

METHODS

We retrospectively included participants with acute LBP included from a larger prospective trial and examined blood samples for the measurement of pro- and anti-inflammatory molecules and measures of pain, disability, and psychological factors at baseline, three and six months.

RESULTS

The serum concentrations of pro- and anti-inflammatory molecules did not differ over time when compared between participants who recovered and those who did not recover at six-month follow-up. At three months, the unrecovered group had higher interleukin (IL)-8 and IL-10 serum concentrations than the recovered group. Baseline psychological factors were not related to inflammatory molecules at any time point.

DISCUSSION

This exploratory study showed that levels of systemic inflammatory molecules did not change over the course of LBP, irrespective of whether people were recovered or unrecovered at six months. There was no relationship between acute-stage psychological factors and systemic inflammatory molecules. Further investigation is needed to elucidate the contribution of pro- and anti-inflammatory molecules to long-term LBP outcome.

The Biology of Chronic Pain and Its Implications for Pain Neuroscience Education: State of the Art

Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findings have on the delivery of pain neuroscience education (PNE). The paper summarizes the various (epi)genetic, neural, endocrine, and immune factors discovered and explored in the scientific literature concerning chronic pain. Each of these biological factors has various implications for the content and delivery of PNE. We discuss the future directions these biological factors have for the clinical implementation of PNE by linking the importance of behavior change, optimizing the learning environment, and using an individualized multimodal treatment approach with PNE. In addition, future directions for research of PNE based on these biological factors are provided with importance placed on individualized patient-centered care and how PNE can be used with traditional modes of care and growing trends with other care methods. PNE was originally and continues to be rooted in understanding chronic pain biology and how that understanding can improve patient care and outcomes.

Neuromuscular adaptations to experimentally induced pain in the lumbar region: systematic review and meta-analysis

ABSTRACT

Experimental pain models are frequently used to understand the influence of pain on the control of human movement. In this systematic review, we assessed the effects of experimentally induced pain in the lumbar region of healthy individuals on trunk muscle activity and spine kinematics. Databases were searched from inception up to January 31, 2022. In total, 26 studies using either hypertonic saline injection (n = 19), heat thermal stimulation (n = 3), nociceptive electrical stimulation (n = 3), or capsaicin (n = 1) were included. The identified adaptations were task dependent, and their heterogeneity was partially explained by the experimental pain model adopted. Meta-analyses revealed an increase of erector spinae activity (standardized mean difference = 0.71, 95% confidence interval [CI] = 0.22-1.19) during full trunk flexion and delayed onset of transversus abdominis to postural perturbation tasks (mean difference = 25.2 ms, 95% CI = 4.09-46.30) in the presence of pain. Low quality of evidence supported an increase in the activity of the superficial lumbar muscles during locomotion and during voluntary trunk movements during painful conditions. By contrast, activity of erector spinae, deep multifidus, and transversus abdominis was reduced during postural perturbation tasks. Reduced range of motion of the lumbar spine in the presence of pain was supported by low quality of evidence. Given the agreement between our findings and the adaptations observed in clinical populations, the use of experimental pain models may help to better understand the mechanisms underlying motor adaptations to low back pain.

Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol

BACKGROUND

Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis.

METHODS

We have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment.

DISCUSSION

By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03581123.

Effectiveness of Spinal Manipulation and Biopsychosocial Self-Management compared to Medical Care for Low Back Pain: A Randomized Trial Study Protocol

Background Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. Methods We have designed a phase 3 randomized trial with a 2x2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. Discussion By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. Trial registration: ClinicalTrials.gov Identifier: NCT03581123.

Identifying body awareness-related brain network changes after Spring Forest Qigong™ practice or P.Volve low-intensity exercise in adults with chronic low back pain: a feasibility Phase I Randomized Clinical Trial

Background

Chronic low back pain (cLBP) affects the quality of life of 52 million Americans and leads to an enormous personal and economic burden. A multidisciplinary approach to cLBP management is recommended. Since medication has limited efficacy and there are mounting concerns about opioid addiction, the American College of Physicians and American Pain Society recommend non-pharmacological interventions, such as mind and body approaches (e.g., Qigong, yoga, Tai Chi) before prescribing medications. Of those, Qigong practice might be most accessible given its gentle movements and because it can be performed standing, sitting, or lying down. The three available Qigong studies in adults with cLBP showed that Qigong reduced pain more than waitlist and equally well than exercise. Yet, the duration and/or frequency of Qigong practice were low (<12 weeks or less than 3x/week). The objectives of this study were to investigate the feasibility of practicing Spring Forest Qigong™ or performing P.Volve low intensity exercises 3x/week for 12 weeks, feasibility of recruitment, data collection, delivery of the intervention as intended, as well as identify estimates of efficacy on brain function and behavioral outcomes after Qigong practice or exercise. To our knowledge, this is the first study investigating the feasibility of the potential effect of Qigong on brain function in adults with cLBP.

Methods

We conducted a feasibility Phase I Randomized Clinical Trial. Of the 36 adults with cLBP recruited between January 2020 and June 2021, 32 were enrolled and randomized to either 12 weeks of remote Spring Forest Qigong™ practice or remote P.Volve low-intensity exercises. Participants practiced at least 3x/week for 41min/session with online videos. Our main outcome measures were the Numeric Pain Rating Scale (highest, average, and lowest cLBP pain intensity levels in the prior week), assessed weekly and fMRI data (resting-state and task-based fMRI tasks: pain imagery, kinesthetic imagery of a Qigong movement, and robot-guided shape discrimination). We compared baseline resting-state connectivity and brain activation during fMRI tasks in adults with cLBP with data from a healthy control group (n=28) acquired in a prior study. Secondary outcomes included measures of function, disability, body awareness, kinesiophobia, balance, self-efficacy, core muscle strength, and ankle proprioceptive acuity with a custom-build device.

Results

Feasibility of the study design and methods was demonstrated with 30 participants completing the study (94% retention) and reporting high satisfaction with the programs; 96% adherence to P.Volve low-intensity exercises, and 128% of the required practice intensity for Spring Forest Qigong™ practice. Both groups saw promising reductions in low back pain (effect sizes Cohen's d =1.01-2.22) and in most other outcomes ( d =0.90-2.33). Markers of ankle proprioception were not significantly elevated in the cLBP group after the interventions. Brain imaging analysis showed weaker parietal operculum and insula network connectivity in adults with cLBP (n=26), compared to data from a healthy control group (n=28). The pain imagery task elicited lower brain activation of insula, parietal operculum, angular gyrus and supramarginal gyrus at baseline in adults with cLBP than in healthy adults. Adults with cLBP had lower precentral gyrus activation than healthy adults for the Qigong movement and robot task at baseline. Pre-post brain function changes showed individual variability: Six (out of 13) participants in the Qigong group showed increased activation in the parietal operculum, angular gyrus, supramarginal gyrus, and precentral gyrus during the Qigong fMRI task.

Interpretation

Our data indicate the feasibility and acceptability of using Spring Forest Qigong™ practice or P.Volve low-intensity exercises for cLBP relief showing promising results in terms of pain relief and associated symptoms. Our brain imaging results indicated brain function improvements after 12 weeks of Qigong practice in some participants, pointing to the need for further investigation in larger studies.

Trial registration number

ClinicalTrials.gov: NCT04164225 .

Self-reported physical function is strongly related to pain behavior and pain interference and weakly related to physical capacity in people with chronic low back pain

BACKGROUND

Inclusion of self-reported and capacity-based measures may help to further elucidate the interactive link between how people think and move.

OBJECTIVE

To characterize the relationship between self-reported factors of physical function and pain with objective physical capacity measures.

DESIGN

Cross-sectional study of 328 adults with chronic low back pain (CLBP).

METHOD

Spearman correlations assessed the relationship between pairs of measures. Multiple linear regression models assessed the association between self-reported measures of physical function and the grouping of physical capacity measures. Self-reported measures included Roland Morris Disability Questionnaire (RMDQ), PROMIS Physical Function, Pain Behavior, and Pain Interference; Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), and Chronic Pain Acceptance Questionnaire (CPAQ). Capacity measures included walking speed and endurance, lower extremity functional strength, lumbopelvic range of motion, and trunk endurance.

RESULTS

PROMIS Physical Function was directly and weakly correlated with walking speed (ρ = 0.26, 2-min walk) and inversely and weakly correlated with lower extremity strength (ρ = -0.29, 5x sit-to-stand). RMDQ was not correlated with any of the capacity-based measures. PROMIS Physical Function was inversely and moderately correlated with Pain Interference (ρ = -0.48) and Pain Behavior (ρ = -0.43), PCS (ρ = -0.36), and FABQ (ρ = -0.31). The RMDQ was strongly correlated with PROMIS Physical Function (ρ = -0.56), Pain Behavior (ρ = 0.51) and Pain Interference (ρ = 0.49); and moderately correlated with PCS (ρ = 0.37) and FABQ (ρ = 0.33). PROMIS Physical Function and RMDQ were not correlated with CPAQ. Lower scores on PROMIS Physical Function were weakly associated with lower measures of lower extremity strength (-0.30, 95% CI: -0.51 to -0.09, p = 0.005). Higher scores on RMDQ were also weakly associated with lower measures of lower extremity strength (0.26, 95% CI: 0.11 to 0.41, p = 0.001).

CONCLUSIONS

A strong association emerged between self-reported limitations in physical function, pain behavior, and pain interference. A weak association emerged between self-reported physical function and lower extremity strength.

Conscious connected breathing with breath retention intervention in adults with chronic low back pain: protocol for a randomized controlled pilot study

BACKGROUND

Chronic pain is a major source of human suffering, and chronic low back pain (cLBP) is among the most prevalent, costly, and disabling of pain conditions. Due to the significant personal and societal burden and the complex and recurring nature of cLBP, self-management approaches that can be practiced at home are highly relevant to develop and test. The respiratory system is one of the most integrated systems of the body, and breathing is bidirectionally related with stress, emotion, and pain. Thus, the widespread physiological and psychological impact of breathing practices and breathwork interventions hold substantial promise as possible self-management strategies for chronic pain. The primary aim of the current randomized pilot study is to test the feasibility and acceptability of a conscious connected breathing with breath retention intervention compared to a sham control condition.

METHODS

The rationale and procedures for testing a 5-day conscious connected breathing with breath retention intervention, compared to a deep breathing sham control intervention, in 24 adults (18-65 years) with cLBP is described. Both interventions will be delivered using standardized audio recordings and practiced over 5 days (two times in-person and three times at-home), and both are described as Breathing and Attention Training to reduce possible expectancy and placebo effects common in pain research. The primary outcomes for this study are feasibility and acceptability. Feasibility will be evaluated by determining rates of participant recruitment, adherence, retention, and study assessment completion, and acceptability will be evaluated by assessing participants' satisfaction and helpfulness of the intervention. We will also measure other clinical pain, psychological, behavioral, and physiological variables that are planned to be included in a follow-up randomized controlled trial.

DISCUSSION

This will be the first study to examine the effects of a conscious connected breathing with breath retention intervention for individuals with chronic pain. The successful completion of this smaller-scale pilot study will provide data regarding the feasibility and acceptability to conduct a subsequent trial testing the efficacy of this breathing self-management practice for adults with cLBP.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT04740710 . Registered on 5 February 2021.

Cross-Cultural Adaptation, Reliability, and Validity of a Hebrew Version of the Physiotherapist Self-Efficacy Questionnaire Adjusted to Low Back Pain Treatment

BACKGROUND

Clinician self-efficacy may be an important factor in the success of treatment for low back pain (LBP), which has unique clinical features and a high prevalence rate. Therefore, it is important to assess clinicians' self-efficacy in this particular condition. The Physiotherapist Self-Efficacy (PSE) questionnaire was designed to measure self-efficacy of physiotherapy students.

OBJECTIVES

To translate and trans-culturally adapt the PSE into Hebrew, to adjust the questionnaire to assess clinicians' self-efficacy in the treatment of LBP, and to assess the construct validity and reliability of the PSE in the Hebrew version.

METHODS

After adjustment for LBP and cross-cultural adaptation, test-retest reliability was assessed with 140 physiotherapists. The analyses used included exploratory factor analysis for structural validity, Cronbach's alpha for internal consistency, and intraclass correlation coefficients (ICC) for test-retest reliability.

RESULTS

Factor analysis revealed a unidimensional structure with an acceptable model fit. The PSE translated into Hebrew exhibited a very high internal consistency (α = 0.93) and excellent test-retest reliability (ICC = 0.94). The standard error of measurement (SEM) and minimal detectable change (MDC) were 1.75 and 4.85, respectively.

CONCLUSIONS

The Hebrew-translated PSE showed adequate validity and excellent reliability, indicating its suitability to measure clinician self-efficacy in treating patients with LBP.

Back pain treatment: a new perspective

This article aims to provide new perspectives for the treatment of low back pain (LBP). A narrative literature review highlights the treatment strategies currently anchored in the guidelines as well as the extensive attempts to identify subgroups within the non-specific low back pain (NSLBP) classification. A variety of multimodal approaches exist for both diagnostic assessments and therapy approaches. Nonetheless, there are often gaps in the classification systems as well as in published treatment concepts with regard to the implementation of musculoskeletal functional disorders. Indeed, a growing body of evidence shows that more holistic and flexible approaches are needed to individually diagnose and target the complexity of LBP. As an example, both a diagnostic and a (independently developed) therapeutic LBP concept will be presented and discussed. Ultimately, guidelines and subgroup classification systems can only reflect the complexity of LBP, if they capture its entire multidimensional and biopsychosocial character in both the diagnostic and therapeutic processes. Furthermore, the expansion of the pain definition to include the nociplastic pain mechanism, as an important driver of LBP, has the potential to provide important impulses for further necessary research. In conclusion, the implementation of a functional musculoskeletal approach along with the emerging nociceptive pain concept in individually targeted holistic approaches seems to be the successful way to deal with the complexity of LBP.

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

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

International Publication Trends in Low Back Pain Research: A Bibliometric and Visualization Analysis

Background

Although there is a growing research base on low back pain, the bibliometric literature related to it is deficient. The aim of this study was to conduct a bibliometric and visualization analysis of low back pain and to provide a broad view of the current trends in LBP research and a potential guide in this discipline.

Methods

The authors searched the Web of Science to extract publications regarding low back pain, and found a total of 12,249 publications during a period of 22 years, among which 12,242 were eligible. We classified and analyzed publications such as total citations, average citations per item, H-index, research types, countries/regions, institutions, and journals using standard bibliometric indicators. Bibliometric approaches (VOSviewer1.6.13 and CiteSpace 5.8.3) were also available for gathering information and explore the trends of research.

Results

Conspicuously, over the past 22 years, an increasing number of scholars have specialized in the research of LBP, exerting the boom in articles. The largest number of document type was that of articles. Under modern conditions, regional distinction existed in the research of low back pain and developed countries preceded others. Research individuals and institutions were preoccupied by respective aspects. Visualization analysis provided objective information for potential collaborators and cooperative institutions. Furthermore, most burst keywords varied during different periods.

Conclusions

The map of research on LBP obtained by our analysis is expected to help researchers to efficiently and effectively explore LBP.

Relationship between gait complexity and pain attention in chronic low back pain

ABSTRACT

Clinical models of chronic low back pain (cLBP) highlight the role of excessive attention to pain and kinesiophobia on the origin of disability. At the motor control level, various mechanisms are involved in the impairments observed in patients with cLBP. We aimed to assess the role of maladaptative attentional behaviors by using a complex systems approach and a visual display as a distraction during walking. Sixteen patients with cLBP with no previous surgery or significant leg pain and 16 healthy matched controls were included. Patients walked on a treadmill at preferred walking speed with and without distraction. Stride time (ST) fractal complexity was assessed using detrended fluctuation analysis. A two-way analysis of variance with repeated measures on distraction was performed on fractal exponents. We found a significant group × distraction interaction effect on fractal complexity of ST series (F(1,30) = 9.972, P = 0.004). Post hoc analysis showed that, without distraction, patients with cLBP had significantly lower ST complexity than controls, but when distracted, they regained gait complexity, recovering the level of controls. Our results suggest that excessive attention to pain causes loss of complexity and adaptability in cLBP and explain alterations of motor control with pain. Fractal analysis seems to be a promising method to explore movement variability and individual adaptability in musculoskeletal disorders.