The Effectiveness of Group-Based Physiotherapy-Led Behavioral Psychological Interventions on Adults With Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Are Tailored Interventions to Modifiable Psychosocial Risk Factors Effective in Reducing Pain Intensity and Disability in Low Back Pain? A Systematic Review with Meta-Analysis of Randomized Trials

OBJECTIVE: To determine whether tailored interventions based on patients' psychological profiles enhanced the outcomes of interventions in people with nonspecific low back pain, compared to usual care. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: Embase, Cochrane, Medline, Web of Science, CINAHL, and PsycINFO were searched from their inception until November 2, 2023. STUDY SELECTION CRITERIA: We included randomized clinical trials that compared psychological interventions to any alternatives without psychological components in patients with nonspecific low back pain who were stratified based on their psychological risk factors using the cutoff of the questionnaires measuring a psychological construct. DATA SYNTHESIS: The outcomes were pain intensity and disability. The revised Cochrane risk-of-bias tool for randomized trials was used to evaluate the risk of bias. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to judge certainty of evidence. RESULTS: Twenty-nine trials were included, most presenting some concerns for the risk of bias. The certainty of evidence was mostly low, with moderate to substantial heterogeneity. Using psychological stratification, individuals who received a psychological intervention (versus usual care) reported lower pain intensity at the short term (MD, -0.22; 95% confidence interval [CI]: -0.41, -0.02) and midterm (MD, -0.37; 95% CI: -0.57, -0.16). For disability, there was a larger improvement with psychological interventions versus usual care at short-term (SMD, -0.17; 95% CI: -0.32, -0.02), midterm (SMD, -0.16; 95% CI: -0.28, -0.05), and long-term (SMD, -0.17; 95% CI: -0.29, -0.04) follow-ups. CONCLUSIONS: Psychological interventions had a positive impact, although small, on reducing pain intensity and disability in patients with low back pain and psychological risk factors. J Orthop Sports Phys Ther 2025;55(2):1-20. Epub 3 January 2025. doi:10.2519/jospt.2025.12777.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

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

How effective are allied health group interventions for the management of adults with long-term conditions? An umbrella review of systematic reviews and its applicability to the Australian primary health system

BACKGROUND

Group allied health interventions for people with chronic conditions may be a solution to increasing access to allied health in primary care. This umbrella review aimed to determine the effectiveness of allied health group interventions to improve health-related outcomes for adults with chronic conditions and the applicability of the findings to the Australian primary health care context.

METHODS

An umbrella review of systematic reviews conducted April-July 2022, searching eight databases. Systematic reviews were eligible if they included randomised controlled trials (RCT) or quasi-RCTs, community dwelling adults aged ≥ 18, at least one chronic condition, group intervention in scope for allied health professionals, and published in English after 2000. Studies were excluded if interventions were conducted in hospital or aged care facilities, out of scope for allied health, or unsupervised.

RESULTS

Two thousand three hundred eighty-five systematic reviews were identified: after screening and full text review 154 were included and data extracted from 90. The chronic conditions included: cancer (n = 15), cardiovascular disease (n = 6), mixed chronic conditions (n = 3), kidney disease (n = 1), low back pain (n = 12), respiratory disease (n = 8), diabetes (n = 14), heart failure (n = 9), risk of falls (n = 5), hypertension (n = 4, osteoarthritis (n = 6) and stroke (n = 8). Most group interventions included prescribed exercise and were in scope for physiotherapists and exercise physiologists. Overall, allied health group exercise programs for community dwelling adults improved health outcomes for most chronic conditions. Aggregated data from the systematic reviews suggests programs of 45-60 min per session, 2-3 times per week for 12 weeks. Lifestyle education and support for people with type-2 diabetes improved glycaemic control.

CONCLUSIONS

Prescribed group exercise delivered by allied health professionals, predominantly by exercise physiologists and physiotherapists, significantly improved health outcomes for community dwelling adults with a broad range of chronic conditions.

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF)

BACKGROUND

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.

AIM

To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.

DESIGN

Clinical practice guideline.

SETTING

Inpatient and outpatient.

POPULATION

Adults with LBP and/or LRS.

METHODS

Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.

RESULTS

The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.

CONCLUSIONS

An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.

CLINICAL REHABILITATION IMPACT

This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Feasibility of a multidisciplinary group videoconferencing approach for chronic low back pain: a randomized, open-label, controlled, pilot clinical trial (EN-FORMA)

BACKGROUND

Low back pain is a common condition that becomes even more prevalent with aging. A non-pharmacological multidisciplinary approach for chronic non-specific low back pain (CNSLBP) has been recommended, but integrating different healthcare professionals is challenging. A multidisciplinary group videoconferencing approach (MGVA) can be helpful. Our aim was to provide evidence on MGVA's feasibility in managing CNSLBP and its impact on clinical practice.

METHODS

We conducted an open-label, randomized, controlled, parallel-group pilot clinical trial with CNSLBP patients irresponsive to conservative treatment. Patients between 18 and 67 years of age were randomly assigned (1:1) to either Standard-of-Care + MGVA (experimental group) or Standard-of-Care alone (control group). MGVA consisted of integrated sessions for physical rehabilitation/physiotherapy, psychology, and social work treatments. The control group received standard clinical practice treatment. The feasibility was assessed by the number of study procedures completed to at least 80% as planned. The impact on clinical practice was evaluated by the number of patients who changed their status from "candidate" to "non-candidate" to low back surgery as the treatment of choice for CNSLBP. The SF-36, Oswestry Disability Index, and TMMS-24 questionnaires were used. We performed a whole population-based descriptive analysis.

RESULTS

We included 20 patients, but only 18 were randomized (2 withdrew consent before randomization). The mean (SD) age was 53.1 (5.9) years, and mostly women (13/18); 7 were actively employed. In the experimental group, 6/9 (67%, 95%CI:35-88%) patients attended at least 80% of the scheduled procedures, while in the control group, 8/9 (89%, 95%CI:57-98%) did. Additionally, 1 out of 4 (25%) patients in the experimental group changed their status from "candidate" for low back surgery to "non-candidate". None of the 2 patients in the control group did so. We found differences between groups in the SF-36 mental health component (p-value:0.061), Oswestry Disability Index (p-value:0.032), and TMMS-24 Repair component (p-value:0.014) at the end of the trial favoring MGVA.

CONCLUSIONS

The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from "candidate" to "non-candidate" for surgery.

TRIAL REGISTRATION

NCT05093543 (ClinicalTrials.gov), first registered in 26/10/2021.

Umbrella Review of Primary Care Treatments for Adults With Chronic Low Back Pain

OBJECTIVES

The purpose of this study was to identify, critically assess, and summarize evidence of the effectiveness of primary care treatments for adults with non-specific chronic low back pain (NSCLBP).

METHODS

We conducted an umbrella review of systematic reviews focusing on primary care treatments for NSCLBP. We searched the PubMed and Cochrane library databases for systematic reviews of randomized controlled trials (RCTs) evaluating primary care treatments for adults with NSCLBP published between January 2007 and March 2021. Two reviewers independently assessed the quality of these systematic reviews using the AMSTAR checklist. We selected systematic reviews with a low or moderate risk of bias and graded the evidence based on Grading of GRADE criteria.

RESULTS

Among the initial 66 systematic reviews meeting our inclusion criteria, 19 systematic reviews with low or moderate bias risk were selected for analysis. These reviews included a total of 365 studies involving 62 832 participants. The evidence suggested moderate to high support for the effectiveness of certain primary care treatments in improving pain and function in NSCLBP patients. These treatments included NSAIDs and opioids compared to placebos, spinal manipulation versus exercise/physical therapy, and MBR versus exercise/education/advice/no treatment.

CONCLUSIONS

Recommendations for specific primary care treatments for NSCLBP in adults remain inconclusive. Further high-quality systematic reviews and RCTs are needed to better understand the effectiveness of these treatments. Future RCTs should prioritize the assessment of NSAIDs, opioids, spinal manipulation, and MBR, as they appear promising for improving NSCLBP outcomes in certain comparisons.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A systematic review with meta-analysis

OBJECTIVE

To evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain.

INTRODUCTION

Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low-dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP).

INCLUSION CRITERIA

Randomized controlled trials that evaluate low-dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary-based rehabilitation (MBR) were excluded.

METHODS

Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13-item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2022 CRD42022302771.

RESULTS

Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta-analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post-treatment (standardized mean difference (SMD) = -1.09, 95% confidence interval (CI) = -1.84 to -0.34, I2  = 97%, p = 0.004) as well as at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004), long term (SMD = -0.79, 95% CI = -1.42 to -0.17, I2  = 96%, p = 0.01) and very long-term (SMD = -1.13, 95% CI = -1.93 to -0.33, I2  = 94%, p = 0.005) follow-up. Significant effects in favor of PCBI for physical function were found post-treatment (SMD = -1.33, 95% CI = -2.17 to -0.49, I2  = 97%, p = 0.002) at short-term (SMD = -0.20, 95% CI = -0.36 to -0.04, I2  = 0%, p = 0.01) and at long-term follow-up (SMD = -1.17, 95% CI = -2.06 to -0.28, I2  = 98%, p = 0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain-neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3-12 weeks) and contact times (2-15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004) and long-term follow-up (SMD = -0.22, 95% CI = -0.41 to -0.03, I2  = 39%, p = 0.02).

CONCLUSIONS

This meta-analysis suggests that low-dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta-analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low-dosed) CLBP interventions.

The group mechanism in treatment: group identification and cohesion contributes to reducing chronic lower back pain by increasing personal control

PURPOSE

There is increasing recognition of the contribution that group processes, particularly identification and cohesion, make to outcomes of group delivered health treatments. This study examined the role that these particular group processes play in the treatment of lower back pain, and a theorised mechanism of personal control through which group treatment might enhance outcomes.

METHODS

Participants (N = 85) elected to either receive NeuroHAB^®, a defined functional movement therapy of 8 weeks duration, or continue with treatment-as-usual (TAU). Pain intensity and disability were assessed at baseline (T1) and post-intervention or 8 weeks later (T2), as well as at a 1-month follow-up (T3). Only the NeuroHAB^® participants additionally completed weekly questionnaires that measured treatment group identification, cohesion, and personal control.

RESULTS

NeuroHAB^® was significantly more effective than TAU in reducing pain intensity and disability at T2 and T3. Furthermore, among NeuroHAB^® recipients, stronger treatment group identification and cohesion early in the program predicted better pain outcomes over time, and this relationship was fully mediated by perceptions of personal control.

CONCLUSION

These data provide further support for the role of group identification and cohesion as a contributing mechanism of change in group-based treatments and extend this to the domain of pain management.Implications for RehabilitationA focus on defined functional movement therapy, as offered by the NeuroHAB^® group program, was found to improve pain outcomes in patients with lower back pain.A key ingredient in the NeuroHAB^® rehabilitation program was its group delivery.Group delivery supported treatment group identification and cohesion which, through enhancing the perception of personal control, reduced pain intensity and disability.

Comparison of supervised exercise therapy with or without biopsychosocial approach for chronic nonspecific low back pain: a randomized controlled trial

Background

A biopsychosocial rehabilitation is recommended for chronic nonspecific low back pain (CNLBP); however, its effectiveness compared to the traditional supervised exercise therapy of CNLBP treatment is still unclear.

Methods

This was a parallel-group randomized controlled clinical trial. The sample consisted of 180 participants of both sexes, aged ≥18 years, with CNLBP for ≥3 months. Using web randomization and concealed allocation, they were assigned to three groups; graded activity receiving cognitive-behavioral therapy, group-based combined exercise therapy and education (GA; n = 59), supervised group-based combined exercise therapy and education (SET; n = 63), and a control group receiving usual care (n = 58). Interventions were administered for 4 weeks (8 sessions). The primary outcome was pain intensity. Outcome measures were collected baseline, after interventions (4 weeks), and during two follow-up periods (3 and 6 months).

Results

After the intervention, GA had a significant large effect on pain reduction compared to the control group (MD of 22.64 points; 95% CI = 16.10 to 29.19; p < 0.0001; Cohen’s d = 1.70), as well as SET compared with the control group (MD of 21.08 points; 95% CI = 14.64 to 27.52; p < 0.0001; Cohen’s d = 1.39), without significant difference between two intervention groups. At 3 and 6 months of follow-up, GA had a statistically significantly better effect in reducing pain, disability and fear-avoidance beliefs, and improving spinal extensor endurance, range of extension and quality of life compared to SET and the control group. A statistically significantly better effect of SET compared with the control group was found in reducing pain, disability, fear-avoidance beliefs, and improving the physical component of quality of life. Harms were not reported.

Conclusion

This study suggests that graded activity and group-based supervised exercise therapy have beneficial effects over the control group in the treatment of CNLBP. The graded activity was more beneficial than supervised group-based exercise therapy only during the follow-up.

Trial registration

Clinicaltrials.gov (NCT04023162; registration date: 17/07/2019).

Bilateral Asymmetrical Limb Proprioceptive Neuromuscular Facilitation Effects on Pain, Multifidus Activity, Range of Motion, and Disability in Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to determine the effects of bilateral asymmetrical limb proprioceptive neuromuscular facilitation (PNF) pattern exercises on lumbar multifidus (LM) activity, pain, disability, and lumbar range of motions (ROMs) compared to Swiss ball exercises in patients with chronic low back pain (CLBP).

METHODS

A randomized controlled trial was conducted at the Sindh Institute of Physical Medicine and Rehabilitation, Karachi, Pakistan, between March 2020 and January 2021. A sample size of 150 patients with CLBP was randomized into 2 groups. Participants in the intervention group (n = 75) received bilateral asymmetrical limb PNF, while the comparison group (n = 75) received Swiss ball exercises. The scores of the visual analog scale, Oswestry Disability Index, Modified-Modified Schober's test, and percentage of the maximum voluntary contractions of LM (%MVC LM) through surface electromyography were recorded before and after 15 sessions of exercises. The Wilcoxon signed rank and Mann-Whitney U tests were employed for within-group and between-group comparisons of all outcomes, respectively. The considered level of significance was 0.05. The trial was registered with ClinicalTrials.gov (NCT04206137).

RESULTS

Pain (in sitting, standing, and walking), disability on the Oswestry Disability Index, and left side %MVC LM were significantly improved (P < .001) in the PNF group compared to the comparison group except for right side %MVC LM and ROMs on the Modified-Modified Schober's test (P > .05).

CONCLUSION

Bilateral asymmetrical limb PNF exercises showed improvement in pain, disability, and LM activity of patients with CLBP more than those who used Swiss ball exercises.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A protocol for a systematic review with meta-analysis

BACKGROUND

Best outpatient treatment of nonspecific chronic low back pain is high-dosed exercise that is maintained after therapy. Primary care biopsychosocial intervention (PCBI) is an outpatient multicomponent intervention that includes an active component (exercise, physical activity, or physiotherapy) and at least one psychological, social, or occupational component. Research has shown that PCBI can reduce pain intensity and disability. While scattered studies support low-dosed (<15 treatment hours) PCBI, there is no systematic review comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP).

INCLUSION CRITERIA

Randomised controlled trials that evaluate low-dosed outpatient biopsychosocial interventions compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older) who suffer from nonspecific CLBP will be included.

METHODS

A comprehensive search of multiple databases will be used to find relevant studies. The databases will be searched from inception to December 2021, with English or German language restrictions imposed. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" will be used. Sources will include CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science.

DISCUSSION

To our knowledge, this will be the first systematic review and meta-analysis of narrowly defined low- dosed PCBI across populations with nonspecific chronic low back pain. The objective of this review is to evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus physical active interventions on pain intensity and disability in adults with CLBP. This study will provide evidence that could improve treatment options for patients with nonspecific CLBP.

TRAIL REGISTRATION

Systematic review registration number: PROSPERO 2022 CRD42022302771. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302771.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear-avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear-avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Physiotherapy informed by Acceptance and Commitment Therapy for chronic low back pain: A mixed-methods treatment fidelity evaluation

OBJECTIVES

A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment.

DESIGN

A mixed-methods study nested within a randomized controlled trial was conducted.

METHODS

A total of 72 (20% of total) PACT treatment audio files were independently assessed by two raters, according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence, and treatment enactment. Interview transcripts from 19 trial participants randomized to PACT were analysed thematically for evidence of treatment receipt and enactment.

RESULTS

PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 11/17 and enactment of 3/17 components; 89% (n = 17) and 47% (n = 9) of participants reported treatment receipt and enactment of at least one component, respectively.

CONCLUSIONS

This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence could be addressed through additional support and adaptations to therapeutic processes for delivery by physiotherapists.

Are Morphometric and Biomechanical Characteristics of Lumbar Multifidus Related to Pain Intensity or Disability in People With Chronic Low Back Pain After Considering Psychological Factors or Insomnia?

INTRODUCTION

Lumbar multifidus muscle (LMM) dysfunction is thought to be related to pain and/or disability in people with chronic low back pain (CLBP). Although psychosocial factors play a major role in pain/disability, they are seldom considered as confounders in analyzing the association between LMM and CLBP.

OBJECTIVES

This study aimed to determine: (1) differences in psychological factors, insomnia, and LMM characteristics between people with and without CLBP; (2) associations between psychological factors, insomnia, or LMM characteristics and low back pain (LBP) intensity or LBP-related disability in people with CLBP; and (3) whether LMM characteristics are related to LBP symptoms in people with CLBP after considering confounders.

METHODS

Seventy-eight volunteers with CLBP and 73 without CLBP provided sociodemographic information, filled the 11-point numeric pain rating scale and Roland-Morris disability questionnaire (RMDQ). They completed the Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), Fear Avoidance Belief Questionnaire (FAB), and Insomnia Severity Index Scale (ISI). Resting and contracted thickness of LMM at L4-S1 levels were measured from brightness-mode ultrasound images. Percent thickness changes of LMM at L4-S1 levels during contraction were calculated. Resting LMM stiffness at L4-S1 was measured by shear wave elastography. Associations among LMM, psychosocial or insomnia parameters and clinical outcomes were analyzed by univariate and multivariate analyses.

RESULTS

People with CLBP demonstrated significantly higher LBP-intensity, RMDQ, HADS, FAB, PCS, and ISI scores than asymptomatic controls (p < 0.05). The former also had significantly smaller percent thickness changes of LMM at L4/L5 during contraction. LBP-intensity was positively related to scores of PCS-total, PCS-helplessness, FAB-total, FAB-work, and ISI in people with CLBP (p < 0.05). RMDQ scores were positively associated with the scores of HADS-total, HADS-depression, PCS-total, FAB-total, FAB-physical activity, PCS-helplessness, and ISI in people with CLBP (p < 0.05). FAB-work and ISI scores together explained 24% of LBP-intensity. FAB-total scores alone explained 34% of variance of LBP-related disability in people with CLBP.

CONCLUSION

More fear-avoidance belief or insomnia is related to greater LBP-intensity and/or LBP-related disability in people with CLBP. Although people with CLBP were thought to have aberrant LMM morphometry/function, no LMM characteristics were related to LBP-intensity or LBP-related disability after considering other confounders.

Self-management at the core of back pain care: 10 key points for clinicians

BACKGROUND

A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

OBJECTIVE

In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

DISCUSSION

People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians' roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

Implementing a behavioral medicine approach in physiotherapy for patients with musculoskeletal pain: a scoping review

In intervention research on musculoskeletal pain, physiotherapists often study behavioral and cognitive components. Evidence on applying these components has increased during the past decade. However, how to effectively integrate behavioral and cognitive components in the biopsychosocial management of musculoskeletal pain is challenging. The aim was to study the intervention components and patient outcomes of studies integrating behavioral and cognitive components in physiotherapy, to match the interventions with a definition of behavioral medicine in physiotherapy and to categorize the behavior change techniques targeted at patients with musculoskeletal pain in (1) randomized controlled effect trials or (2) implementation in clinical practice trials. A scoping review was used to conduct this study, and the PRISMA-ScR checklist was applied. Relevant studies were identified from the PubMed, MEDLINE, PsycINFO, CINAHL Plus, and Web of Science Core databases separately for the (1) randomized controlled effect trials and (2) implementation in clinical practice trials. Synthesis for the matching of the patient interventions with the existing definition of behavior medicine in physiotherapy showed that the interventions mostly integrated psychosocial, behavioral, and biomedical/physical aspects, and were thus quite consistent with the definition of behavioral medicine in physiotherapy. The reported behavior change techniques were few and were commonly in categories such as "information of natural consequences," "feedback and monitoring," and "goals and planning." The patient outcomes for long-term follow-ups often showed positive effects. The results of this scoping review may inform future research, policies, and practice.

Chronic Pain Patients' Kinesiophobia and Catastrophizing are Associated with Activity Intensity at Different Times of the Day

Purpose

To examine the relationship between baseline kinesiophobia and baseline pain catastrophizing with the 4-day average activity intensity at different times of the day while accounting for different wake and sleep-onset times in chronic pain patients.

Methods

Twenty-one participants suffering from idiopathic chronic pain completed baseline questionnaires about kinesiophobia, catastrophizing, disability, depression, and pain. We measured the participants' activity using accelerometers and calculated activity intensity in the morning, afternoon, and evening. We performed a 2-way repeated measures ANOVA to compare activity levels at different times of the day, and multiple linear regressions.

Results

Baseline kinesiophobia was significantly associated with 4-day average evening light activity and sedentary activity at all time periods while baseline catastrophizing was significantly associated with increased 4-day average light activity in the evening and more moderate to vigorous activity in the morning. Our participants engaged in more light activity on average than sedentary activity, and very little moderate-vigorous activity. Participants were most active in the afternoon.

Conclusion

Baseline kinesiophobia and baseline catastrophizing were not associated with the 4-day average total daily activity; however, they were associated with 4-day average activity intensities at different times throughout the day. Segmenting daily activity into morning, afternoon, evening may influence the relationship between daily activity, and kinesiophobia and pain catastrophizing. Individuals with chronic pain are less sedentary than previously thought which may affect future interventions.

Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain

Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP management. Taking into account the scale and costs of CLBP, it is imperative that healthcare professionals have access to up-to-date, evidence-based information to assist them in treatment decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews, meta-analysis and available treatment guidelines, most physically inactive therapies should not be considered for CLBP management, except for pain neuroscience education and spinal manipulative therapy if combined with exercise therapy, with or without psychological therapy. Regarding active therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises should not be considered due to low-quality and/or conflicting evidence. Exercise interventions on the other hand are recommended, but while all exercise modalities appear effective compared to minimal/passive/conservative/no intervention, there is no evidence that some specific types of exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient's preferences and abilities. When exercise interventions are combined with a psychological component, effects are better and maintain longer over time.