Which Exercise for Low Back Pain? (WELBack) trial predicting response to exercise treatments for patients with low back pain: a validation randomised controlled trial protocol

Machine learning-based identification of determinants for rehabilitation success and future healthcare use prevention in patients with high-grade, chronic, nonspecific low back pain: an individual data 7-year follow-up analysis on 154,167 individuals

ABSTRACT

To individually prescribe rehabilitation contents, it is of importance to know and quantify factors for rehabilitation success and the risk for a future healthcare use. The objective of our multivariable prediction model was to determine factors of rehabilitation success and the risk for a future healthcare use in patients with high-grade, chronic low back pain. We included members of the German pension fund who participated from 2012 to 2019 in multimodal medical rehabilitation with physical and psychological treatment strategies because of low back pain (ICD10:M54.5). Candidate prognostic factors for rehabilitation success and for a future healthcare use were identified using Gradient Boosting Machines and Random Forest algorithms in the R-package caret on a 70% training and a 30% test set. We analysed data from 154,167 patients; 8015 with a second medical rehabilitation measure and 5161 who retired because of low back pain within the study period. The root-mean-square errors ranged between 494 (recurrent rehabilitation) and 523 (retirement) days ( R2 = 0.183-0.229), whereas the prediction accuracy ranged between 81.9% for the prediction of the rehabilitation outcome, and 94.8% for the future healthcare use prediction model. Many modifiable prognostic factors (such as duration of the rehabilitation [inverted u-shaped], type of the rehabilitation, and aftercare measure), nonmodifiable prognostic factors (such as sex and age), and disease-specific factors (such as sick leave days before the rehabilitation [linear positive] together with the pain grades) for rehabilitation success were identified. Inpatient medical rehabilitation programmes (3 weeks) may be more effective in preventing a second rehabilitation measure and/or early retirement because of low back pain compared with outpatient rehabilitation programs. Subsequent implementation of additional exercise programmes, cognitive behavioural aftercare treatment, and following scheduled aftercare are likely to be beneficial.

The Effects of Combined Motor Control and Isolated Extensor Strengthening versus General Exercise on Paraspinal Muscle Morphology, Composition, and Function in Patients with Chronic Low Back Pain: A Randomized Controlled Trial

Low back pain (LBP), a globally widespread and persistent musculoskeletal disorder, benefits from exercise therapy. However, it remains unclear which type leads to greater changes in paraspinal muscle health. This study aimed to (1) compare the effects of a combined motor control and isolated lumbar extension exercise (MC+ILEX) versus a general exercise (GE) intervention on paraspinal muscle morphology, composition, and function, and (2) examine whether alterations in paraspinal muscle health were correlated with improvements in pain, function, and quality of life. Fifty participants with chronic LBP were randomly assigned to each group and underwent a 12-week supervised intervention program. Magnetic resonance imaging and ultrasound assessments were acquired at baseline, 6 and 12 weeks to examine the impact of each intervention on erector spinae (ES) and multifidus (MF) muscle size (cross-sectional area, CSA), composition, and function at L4-L5 and L5-S1. Self-reported questionnaires were also acquired to assess participant-oriented outcomes. Our findings indicated that the MC+ILEX group demonstrated greater improvements in MF and ES CSA, along with MF thickness at both levels (all p < 0.01). Both groups significantly improved in pain, function, and quality of life. This study provided preliminary results suggesting that an MC+ILEX intervention may improve paraspinal morphology while decreasing pain and disability.

The impact on physical performance, pain and psychological wellbeing of chronic low back pain patients during 12-weeks of equine- facilitated therapy intervention

Equine - Facilitated Therapy (EFT), an equine environment, and horses themselves can meet many physical and mental health needs beyond diagnostic categories. The horse's ability to produce a walk-like movement and the participant's ability to connect to non-judgemental living creatures, both of which can benefit participation and construct a positive self-image for chronic pain patients. The objective of this study is to evaluate the impact of EFT on perceived physical performance, level of pain, pain acceptance, depression and anxiety, and quality of life within a 12-week intervention for chronic low back pain (LBP) patients. Twenty-two LBP patients received EFT led by physical therapists as part of the public health services. A mixed method design combining quantitative and qualitative methods was employed to detect the outcome of the intervention. The data were collected via questionnaires, interviews, and patient data repositories. An interview was voluntary for participants and included questions of one's health, visits to the pain clinic during 6 months and an open-ended question about the intervention. The coding of the data was completed independently by two persons using thematizing. The welfare of the attending horses was taken into consideration in basic training and for the research setting. Statistical analysis and paired t-tests detected the changes during a 12-week intervention. The results suggest a significant increase in Canadian Occupational Performance Measure (COPM) levels of satisfaction with self-selected performances. The Raitasalo's version of Beck's Depression Inventory (RBDI) level of anxiety and Chronic Pain Acceptance Questionnaire (CPAQ) did not change, whereas a decline in the amount of perceived RBDI depression was found combined with increased levels of SF-36 Mental Change Scores and COPM satisfaction with performance. Only two of the 22 participants returned with reoccurring symptoms after 6 months to the pain clinic. The participant interviews revealed three important domains of experience during coding: physical-, psychological-, and social that link to the research question and suggest impact for the recovery from the human-animal interaction.

What Modifies the Effect of an Exercise Treatment for Chronic Low Back Pain? A Meta-epidemiologic Regression Analysis of Risk of Bias and Comparative Effectiveness

OBJECTIVE: To investigate how risk of bias and intervention type modify effect sizes of exercise interventions that are intended to reduce chronic low back pain intensity. DESIGN: Systematic review with meta-epidemiologic regression analysis. LITERATURE SEARCH: PubMed, CENTRAL, Embase, and CINAHL (until January 31, 2021). STUDY SELECTION CRITERIA: Systematic reviews with meta-analyses of randomized controlled exercise trials. DATA SYNTHESIS: The dependent variable was pain, calculated as standardized mean difference (SMD). Potential effect modifiers were risk of bias, exercise modes, study, and meta-analyses characteristics. Multilevel meta-regressions and inverse variance-weighted meta-regressions with random intercepts were modelled. RESULTS: Data from 26 systematic reviews (k = 349 effect sizes, n = 18,879 participants) were analysed. The overall mean effect was SMD: -0.35 (k = 349, [95% CI -0.02 to -0.7]). There was a clinically relevant effect overestimation in studies with a high risk of bias due to missing outcomes (each k = 197, Beta coefficient = -1.9 [95% CI -2.9 to -.9]) and low sample size (B = 0.01 [.001 to .01], [ie, one participant more leads to an SMD decrease of 0.01]). There was a clinically relevant underestimation of the effect when studies were at high risk of bias in allocation concealment (B = 1.3 [.5 to 2.1]) and outcome measurement (B = 1.3 [.44 to 2.0]). Motor control and stabilization training (B = -1.3 [-2.3 to -.37]) had the largest effects; stretching (B = 1.3 [-.03 to .5]) had the smallest effect. CONCLUSIONS: The effects of exercise trials at high risk of bias may be overestimated or underestimated. After accounting for risk of bias, motor control and stabilization exercises may represent the most effective exercise therapies for chronic low back pain. J Orthop Sports Phys Ther 2022;52(12):792-802. Epub: 12 August 2022. doi:10.2519/jospt.2022.11149.

Individualized Exercise in Chronic Non-Specific Low Back Pain: A Systematic Review with Meta-Analysis on the Effects of Exercise Alone or in Combination with Psychological Interventions on Pain and Disability

This systematic review, meta-analysis and meta-regression investigated the effects of individualized interventions, based on exercise alone or combined with psychological treatment, on pain intensity and disability in patients with chronic non-specific low-back-pain. Databases were searched up to January 31, 2022 to retrieve respective randomized controlled trials of individualized and/or personalized and/or stratified exercise interventions with or without psychological treatment compared to any control. Fifty-eight studies (n = 10084) were included. At short-term follow-up (12 weeks), low-certainty evidence for pain intensity (SMD -0.28 [95%CI -0.42 to -0.14]) and very low-certainty evidence for disability (-0.17 [-0.31 to -0.02]) indicates effects of individualized versus active exercises, and very low-certainty evidence for pain intensity (-0.40; [-0.58 to -0.22])), but not (low-certainty evidence) for disability (-0.18; [-0.22 to 0.01]) compared to passive controls. At long-term follow-up (1 year), moderate-certainty evidence for pain intensity (-0.14 [-0.22 to -0.07]) and disability (-0.20 [-0.30 to -0.10]) indicates effects versus passive controls. Sensitivity analyses indicates that the effects on pain, but not on disability (always short-term and versus active treatments) were robust. Pain reduction caused by individualized exercise treatments in combination with psychological interventions (in particular behavioral-cognitive therapies) (-0.28 [-0.42 to -0.14], low certainty) is of clinical importance. Certainty of evidence was downgraded mainly due to evidence of risk of bias, publication bias and inconsistency that could not be explained. Individualized exercise can treat pain and disability in chronic non-specific low-back-pain. The effects at short term are of clinical importance (relative differences versus active 38% and versus passive interventions 77%), especially in regard to the little extra effort to individualize exercise. Sub-group analysis suggests a combination of individualized exercise (especially motor-control based treatments) with behavioral therapy interventions to booster effects. PERSPECTIVE: The relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance. Still, sustainability of effects (> 12 months) is doubtable. As individualization in exercise therapies is easy to implement, its use should be considered. PROSPERO REGISTRATION: CRD42021247331.

Dose-response relationship and effect modifier of stabilisation exercises in non-specific low back pain: a project-wide individual patient data re-analysis on 1,483 intervention participants

ABSTRACT

To derive a dose-response relationship under consideration of further effect modifiers in exercises on low back pain.In this planned MiSpEx-Network re-analysis, 1,483 intervention participants with low back pain (mean age 40.9 years (SD 14 years)) performed stabilisation exercises (3 weeks supervised, 9 weeks self-administered). Patients reported pain intensity, disability and disability days at baseline, 3 weeks, 12 weeks and 6 months post-randomisation. Exercise characteristics and effect modifiers were prospectively monitored. Beyond the comparison to the aggregated control group, linear mixed models were calculated to determine a dose-response-relationship.The interventions led to small but significantly larger symptom reductions than the control at each measurement. Longer durations of the intervention led to larger symptom reductions. Higher exercise frequencies were associated with a decrease in pain intensity: to train once more per week led to a mean decrease of 0.93 points in pain intensity [95% CI= -1.54 to -0.32]. Disability days were also impacted (estimate=-0.07 [-0.14 to 0.00]), disability was not (-0.09 [-0.67 to 0.48]). Adding perturbation was superior to adding stretching or a behavioural module. The relationships were robust when additional effect modifiers were considered and against the control group' effects. The odds ratio for a clinically important effect with higher exercise frequencies decreased at 3 weeks (OR=0.71 [0.618 to 0.813] for >2.5*week -1 ) and increased at 12 weeks (1.13 [1.006 to 1.270], >1.5*week -1 ).Using longer intervention durations, adding a perturbation component to the stabilisation trainings and utilising higher frequencies (up to a certain point) may lead to an even more beneficial response in patients with low back pain. Developing strategies to maintain a training frequency of at least two times per week may be relevant in stabilisation exercises to treat low back pain.

Non-surgical therapy for the treatment of chronic low back pain in patients with Modic changes: A systematic review of the literature

Background

In absence of uniform therapeutic recommendations, knowledge of the available treatment options for Modic changes (MCs) patients and their safety and effectiveness would be crucial and significant for clinicians and such patients.

Objectives

The aim of this study was to provide a systematic review of available studies on non-surgical treatments of MCs.

Methods

We performed a systematic review of multiple electronic databases including PubMed, Web of Science, Embase, Cochrane Library, and China National Knowledge Infrastructure for the period until 31st August 2021 to search for studies on non-surgical treatments for MCs in accordance with the guidance of the Cochrane Handbook. Potential studies were screened by their titles and abstracts. The methodological quality of the included studies was independently evaluated by two authors. Final recommendations for the included interventions were developed based on grades of recommendations. The narrative format was adopted to synthesize the findings of the present work.

Results

Fifth studies involving a total of 1147 patients were identified for this systematic review. The results of this review demonstrated that spinal manipulation has been suggested as an alternative option for patients with MCs. However, there was insufficient evidence to support that patients with MCs can benefit from the medication and wearing the rigid lumbar brace. Moreover, the rationale and safety for the use of antibiotics in such patients remain highly controversial. Low evidence revealed that exercise therapy might decrease pain intensity only for special subgroups of MCs patients.

Conclusions

There is not yet enough evidence to suggest that non-surgical treatments are useful for patients with MCs. Further high-quality, multicenter trials are required to validate the effectiveness of these non-surgical treatments.

The effects of combined motor control and isolated extensor strengthening versus general exercise on paraspinal muscle morphology and function in patients with chronic low back pain: a randomised controlled trial protocol

Background

Exercise is a common approach for the management of patients with chronic non-specific low back pain (LBP). However, there is no clear mechanistic evidence or consensus on what type of exercise is more effective than others. While considerable evidence suggests a link between lumbar muscle health (e.g., atrophy and fatty infiltration) with functional deficits, it is unknown whether exercises targeting the lumbar spine can lead to noticeable improvements in muscle health and functional outcomes. The primary aim of this study is to compare the effect of combined motor control and isolated strengthening lumbar exercises (MC + ILEX) versus a general exercise group (GE) on multifidus muscle morphology (size and composition). Secondary aims include assessing the effect of the interventions on overall paraspinal muscle health, pain and disability, as well as psychological factors as possible effect modifiers.

Methods

A total of 50 participants with chronic non-specific LBP and moderate to severe disability, aged between 18 and 60, will be recruited from the local orthopaedic clinics and university community. Participants will be randomised (1:1) to either the MC + ILEX or GE group. Participants will undergo 24 individually supervised exercise sessions over a 12-week period. The primary outcome will be multifidus morphology (atrophy) and composition (fatty infiltration). Secondary outcomes will be muscle function (e.g., % thickness change during contraction), morphology, lumbar extension strength, pain intensity and disability. Potential treatment effect modifiers including maladaptive cognitions (fear of movement, catastrophizing), anxiety, depression, physical activity, and sleep quality will also be assessed. All measurements will be obtained at baseline, 6-week and 12-week; self-reported outcomes will also be collected at 24-week. Between-subjects repeated measure analysis of variance will be used to examine the changes in paraspinal muscle morphology over the different time points. Linear mixed models will be used to assess whether baseline scores can modify the response to the exercise therapy treatment.

Discussion

The results of this study will help clarify which of these two common interventions promote better results in terms of overall paraspinal muscle heath, back pain, disability and psychological factors in adults with chronic LBP.

Trial registration

NTCT04257253, registered prospectively on February 5, 2020.