The natural course of low back pain: a systematic critical literature review

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.

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.

Motion Analysis of Core Stabilization Exercise in Women: Kinematics and Electromyographic Analysis

As core stabilization exercise is essential for maintaining a stable spine and improving functional performance, understanding the activation of core muscles and the stabilization of the trunk and pelvis during such exercise is crucial. The purpose of this study was to investigate the muscle activation and stabilization of the lumbar–pelvic region during core stabilization exercise, with a specific focus on analyzing EMG and 3D motion kinematic data. The study aimed to understand how different tension settings on the reformer affect muscle activation and hip motion, as well as how these factors impact pelvic and trunk stability during the exercise. The reformer consists of a carriage that slides back and forth on rails, with springs providing resistance. The springs can be adjusted to vary the resistance level. Twenty-eight healthy women participating in this study were asked to perform ‘side splits’, a hip abduction exercise, on the reformer in both heavy and light tension settings. Activation of the internal oblique (IO), rectus abdominis (RA), multifidus (MU), costal lumbosacral (IL), gluteus medius (GM), and adductor muscles (AL) were measured using electromyography (EMG) and 3D motion. Kinematic data using an assay were also measured during exercise. GM, IO, and MU muscles were more active when heavy springs were used, and AL muscles were more active when light springs were used. Hip motion was more symmetrical when lighter springs were used with a greater range of hip motion. There was less pelvis and torso weight transfer and more torso and pelvis stability when the heavier springs were used. In this study, we confirmed that core stabilization exercise on an unstable surface activates the deep muscles of the abdomen and back and is effective for pelvic and trunk stabilization training.

Endplate role in the degenerative disc disease: A brief review

The degenerative disease of the intervertebral disc is nowadays an important health problem, which has still not been understood and solved adequately. The vertebral endplate is regarded as one of the vital elements in the structure of the intervertebral disc. Its constituent cells, the chondrocytes in the endplate, may also be involved in the process of the intervertebral disc degeneration and their role is central both under physiological and pathological conditions. They main functions include a role in homeostasis of the extracellular environment of the intervertebral disc, metabolic support and nutrition of the discal nucleus and annulus beneath and the preservation of the extracellular matrix. Therefore, it is understandable that the cells in the endplate have been in the centre of research from several viewpoints, such as development, degeneration and growth, reparation and remodelling, as well as treatment strategies. In this article, we briefly review the importance of vertebral endplate, which are often overlooked, in the intervertebral disc degeneration.

What can we learn from long-term studies on chronic low back pain? A scoping review

PURPOSE

A scoping review was conducted with the objective to identify and map the available evidence from long-term studies on chronic non-specific low back pain (LBP), to examine how these studies are conducted, and to address potential knowledge gaps.

METHOD

We searched MEDLINE and EMBASE up to march 2021, not restricted by date or language. Experimental and observational study types were included. Inclusion criteria were: participants between 18 and 65 years old with non-specific sub-acute or chronic LBP, minimum average follow-up of > 2 years, and studies had to report at least one of the following outcome measures: disability, quality of life, work participation, or health care utilization. Methodological quality was assessed using the Effective Public Health Practice Project quality assessment. Data were extracted, tabulated, and reported thematically.

RESULTS

Ninety studies met the inclusion criteria. Studies examined invasive treatments (72%), conservative (21%), or a comparison of both (7%). No natural cohorts were included. Methodological quality was weak (16% of studies), moderate (63%), or strong (21%) and generally improved after 2010. Disability (92%) and pain (86%) outcomes were most commonly reported, followed by work (25%), quality of life (15%), and health care utilization (4%). Most studies reported significant improvement at long-term follow-up (median 51 months, range 26 months-18 years). Only 10 (11%) studies took more than one measurement > 2 year after baseline.

CONCLUSION

Patients with persistent non-specific LBP seem to experience improvement in pain, disability and quality of life years after seeking treatment. However, it remains unclear what factors might have influenced these improvements, and whether they are treatment-related. Studies varied greatly in design, patient population, and methods of data collection. There is still little insight into the long-term natural course of LBP. Additionally, few studies perform repeated measurements during long-term follow-up or report on patient-centered outcomes other than pain or disability.

The Endplate Role in Degenerative Disc Disease Research: The Isolation of Human Chondrocytes from Vertebral Endplate—An Optimised Protocol

Background: Degenerative disc disease is a progressive and chronic disorder with many open questions regarding its pathomorphological mechanisms. In related studies, in vitro organ culture systems are becoming increasingly essential as a replacement option for laboratory animals. Live disc cells are highly appealing to study the possible mechanisms of intervertebral disc (IVD) degeneration. To study the degenerative processes of the endplate chondrocytes in vitro, we established a relatively quick and easy protocol for isolating human chondrocytes from the vertebral endplates. Methods: The fragments of human lumbar endplates following lumbar fusion were collected, cut, ground and partially digested with collagenase I in Advanced DMEM/F12 with 5% foetal bovine serum. The sediment was harvested, and cells were seeded in suspension, supplemented with special media containing high nutrient levels. Morphology was determined with phalloidin staining and the characterisation for collagen I, collagen II and aggrecan with immunostaining. Results: The isolated cells retained viability in appropriate laboratory conditions and proliferated quickly. The confluent culture was obtained after 14 days. Six to 8 h after seeding, attachments were observed, and proliferation of the isolated cells followed after 12 h. The cartilaginous endplate chondrocytes were stable with a viability of up to 95%. Pheno- and geno-typic analysis showed chondrocyte-specific expression, which decreased with passages. Conclusions: The reported cell isolation process is simple, economical and quick, allowing establishment of a viable long-term cell culture. The availability of a vertebral endplate cell model will permit the study of cell properties, biochemical aspects, the potential of therapeutic candidates for the treatment of disc degeneration, and toxicology studies in a well-controlled environment.

Spinal health in 40 patients in the initial stage of laboural life. Morfogeometric, biological and environmental study

Introduction

Assuming that spinal shape is a genetic expression, its analysis and acquired factors could assess their respective contribution to early spine deterioration.

Material and methods

A geometric morphometric analysis was retrospectively performed on sagittal lumbar MRI of young patients with back pain to identify lumbar spine shape changes. Using Geometric Morphometrics, findings were analyzed with anthropometric, radiological, and clinical variables.

Results

80 cases under 26 years of age were collected, 55 men (mean age 22.81) and 25 women (mean age 23.24). MRI abnormalities were reported in 57.5%: single altered disc (N=17), root compromises (N=8), and transition anomalies (35%).In the non-normal MRI subgroup, shape variation included: increased lordosis, enlarged vertebral body, canal stenosis, and lumbarization of S1. In non-Spanish origin patients, lumbar straightening and segmental deformities were prevalent. Morphometrics findings showed that lumbosacral transition anomalies are frequently underreported.

Conclusions

Genetic factors could be the main determinants of abnormality in MRIs under 26 years. The primary markers are transitional abnormalities, segmental deformities, and canal stenosis. In foreign populations, shape changes could suggest spine overload at an early age.

Chronic widespread pain in children and adolescents presenting in primary care: prevalence and associated risk factors

ABSTRACT

A significant proportion of children/adolescents report chronic widespread pain (CWP), but little is known about clinically relevant CWP or what factors lead to onset in this population. Objectives were to report the primary care consultation prevalence of CWP and investigate risk factors associated with onset. A validated algorithm for identifying CWP status from primary care electronic healthcare records was applied to a child or adolescent population (aged 8-18 years). The algorithm records patients who have recurrent pain consultations (axial skeleton and upper or lower limbs) or those with a nonspecific generalised pain disorder (eg, fibromyalgia). Prevalence was described, and a nested case-control study was established to identify risk factors associated with CWP onset using logistic regression producing odds ratios (ORs) and 95% confidence intervals (95% CIs). Two hundred seventy-one children or adolescents were identified with CWP, resulting in a 5-year consultation prevalence of 3.19%. Risk factors significantly associated with CWP onset were as follows: mental health (eg, anxiety/neurosis consultations), neurological (eg, headaches), genitourinary (eg, cystitis), gastrointestinal (eg, abdominal pain), and throat problems (eg, sore throats). Children or adolescents with 1 or 2 risk factors (OR 2.15, 95% CI 1.6-2.9) or 3 or more risk factors (OR 9.17, 95% CI 5.9-14.3) were at significantly increased odds of CWP onset compared with those with none. Findings show a significant proportion of the child or adolescent primary care population has CWP. Most risk factors involved pain-related conditions, suggesting potential pathways of pain development. Further work is now needed to better understand the development of CWP in children and adolescents.

ACTIVATION OF LUMBAR SPINE STABILIZER MUSCLES IN PEOPLE WITH CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW

ABSTRACT Objective: To compare the level of activation of the lumbar spine stabilizing muscles between people with chronic low back pain and healthy people. Methods: A systematic search was performed on May 10, 2021, of the following databases: PubMed, Physiotherapy Evidence Database and Cochrane Library. Inclusion and exclusion criteria were based on the PICO format. Two authors independently examined all articles that were selected for full reading. Disagreements were resolved through a discussion between the authors. Results: The bibliographical search identified 525 records, 165 of which were duplicates. After screening the titles, abstracts and the full text of the remaining 360 studies, 352 articles were excluded, and 8 articles were included in this review. The eight studies assessed the level of muscle activation in patients with chronic low back pain. In six studies patients with chronic low back pain had a higher activation level, in one study there was no statistically significant difference between groups,and in one study the activation level was lower in the chronic low back pain group. Discussion: This review was the first to review electromyography studies of the lumbar spine stabilizer muscles, covering all types of exposure procedures for evaluation. We believe that the recommendation of healthcare professionals for these patients to contract the stabilizer muscles are totally unnecessary. Conclusion: Patients with low back pain have a higher level of lumbar spine stabilizer muscle activation than healthy people. Level of evidence IIA; Systematic review of cohort studies.

Prevalence and Risk Factors Associated with Low Back Pain in the Saudi Adult Community: A Cross-Sectional Study

Worldwide, low back pain is common and linked with many risk factors. There is a lack of studies in the Saudi Arabian community on low back pain prevalence and risk factors. Therefore, the present research will investigate the prevalence of low back pain in the middle-aged and elderly community population and examine the risk factors contributing to low back pain in Saudi Arabia. The present paper is a cross-sectional study of the community living in Riyadh and the surrounding areas in Saudi Arabia. Data were collected between October 2019 and April 2020 via trained research assistants. A total of 276 participants were included in the analysis. The prevalence of low back pain was 27.9% (n = 77) among the participants included in this study. All participants reported low back pain severity with a mean of 4.35 ± 2.19 on the pain rating scale. Older age, arthritis, hypertension, anemia, osteoporosis, and a history of fractures were all associated with having LBP. Low back pain is highly prevalent in the Saudi community adult population living in Riyadh and its surrounding areas. More than a fourth of the sample reported experiencing back pain. The study outlines several modifiable risk factors (BMI, education, employment status, marital status, and smoking status) and unmodifiable risk factors (arthritis, hypertension, anemia, osteoporosis, and a history of fractures) associated with low back pain in the study sample.

Trajectories of low back pain from midlife to retirement and functional ability at old age

BACKGROUND

This study aimed to identify trajectories of low back pain (LBP) over a 16-year follow-up from midlife to retirement and investigate their association with mobility limitations and disability in activities of daily living (ADL-disability) in later life.

METHODS

The study population consisted of 6257 baseline (1981) respondents aged 44-58 years from Finnish Longitudinal study on Aging Municipal Employees. Repeated measurements of LBP were collected in 1985, 1992 and 1997. We studied persons who had data on LBP at baseline and in at least one of the follow-ups and had information on mobility limitations (n = 2305) and ADL-disability (n = 2359) at a 28-year follow-up in 2009. Latent class growth analysis was used to identify LBP trajectories. Odds ratios (ORs) with 95% confidence intervals (CIs) for the associations of LBP trajectory and later life mobility limitations and ADL-disability were estimated and adjusted for confounders.

RESULTS

Three LBP trajectories with parallel shapes were identified: high-decreasing (19%), intermediate-stable (60%) and low (21%). After adjustment for confounders, high-decreasing trajectory had 3.2 times the odds (95% CI 2.1-4.9) of mobility limitations and 2.9 times the odds (95% CI 2.0-4.2) of ADL-disability as compared to low trajectory. The respective ORs for intermediate-stable trajectory were 1.6 (95% CI 1.2-2.1) and 1.7 (95% CI 1.3-2.3).

CONCLUSIONS

Among majority of respondents, LBP remained stable over the follow-up. The respondents belonging to intermediate-stable and high-decreasing trajectories of LBP had higher odds of mobility limitations and ADL-disability at old age. This highlights that LBP during midlife to retirement has far-reached consequences on functional ability at old age.

Involving practice nurse and other assistant clinical staff members in the management of low back pain: A qualitative interview study from Danish general practice

Objectives

Involving practice nurse and other assistant clinical staff members in providing information and education to patients with low back pain at follow-up appointments may release more time and improve care in general practice. However, this requires a shift in the division of tasks, and general practitioners' barriers and facilitators for this are currently unknown. The objectives were to explore general practitioners' experiences and perceptions of including assistant clinical staff members in the management of low back pain.

Methods

This is a semi-structured interview study in Danish general practice. General practitioners with a variation in demographics and experience with task-delegation to clinical staff were recruited for in-depth interviews. We used a phenomenological approach to guide the data collection and the analysis in order to gain insight into the subjective experiences of the general practitioners and to understand the phenomenon of 'delegating tasks to practice staff' from the perspective of the general practitioners' lifeworld. Analysis was conducted using an inductive descriptive method. The sample size was guided by information power.

Results

We conducted five interviews with general practitioners. All general practitioners had experience with task delegation, but there was a variation in which tasks the general practitioners delegated and to which types of clinical staff members. The following themes were derived from the analysis: general practice organisation, delegating to clinical staff members, doctor-patient relationship, exercise instruction, clinical pathway for patients and external support.

Conclusion

General practitioners consider patients with low back pain to be a heterogeneous group with a variety of treatment needs and a patient group without any predetermined content or frequency of consultations; this can be a barrier for delegating these patients to clinical staff members.

The Online Patient Satisfaction Index for Patients With Low Back Pain: Development, Reliability, and Validation Study

Background

Low back pain is highly prevalent, and most often, a specific causative factor cannot be identified. Therefore, for most patients, their low back pain is labeled as nonspecific. Patient education and information are recommended for all these patients. The internet is an accessible source of medical information on low back pain. Approximately 50% of patients with low back pain search the internet for health and medical advice. Patient satisfaction with education and information is important in relation to patients’ levels of inclination to use web-based information and their trust in the information they find. Although patients who are satisfied with the information they retrieve use the internet as a supplementary source of information, dissatisfied patients tend to avoid using the internet. Consumers’ loyalty to a product is often applied to evaluate their satisfaction. Consumers have been shown to be good ambassadors for a service when they are willing to recommend the service to a friend or colleague. When consumers are willing to recommend a service to a friend or colleague, they are also likely to be future users of the service. To the best of our knowledge, no multi-item instrument exists to specifically evaluate satisfaction with information delivered on the web for people with low back pain.

Objective

This study aims to report on the development, reliability testing, and construct validity testing of the Online Patient Satisfaction Index to measure patients’ satisfaction with web-based information for low back pain.

Methods

This is a cross-sectional validation study of the Online Patient Satisfaction Index. The index was developed with experts and assessed for face validity. It was subsequently administered to 150 adults with nonspecific low back pain. Of these, 46% (70/150) were randomly assigned to participate in a reliability test using an intraclass correlation coefficient of agreement. Construct validity was evaluated by hypothesis testing based on a web app (MyBack) and Wikipedia on low back pain.

Results

The index includes 8 items. The median score (range 0-24) based on the MyBack website was 20 (IQR 18-22), and the median score for Wikipedia was 12 (IQR 8-15). The entire score range was used. Overall, 53 participants completed a retest, of which 39 (74%) were stable in their satisfaction with the home page and were included in the analysis for reliability. Intraclass correlation coefficient of agreement was estimated to be 0.82 (95% CI 0.68-0.90). Two hypothesized correlations for construct validity were confirmed through an analysis using complete data.

Conclusions

The index had good face validity, excellent reliability, and good construct validity and can be used to measure satisfaction with the provision of web-based information regarding nonspecific low back pain among people willing to access the internet to obtain health information.

Trial Registration

ClinicalTrials.gov NCT03449004; https://clinicaltrials.gov/ct2/show/NCT03449004

The clinical course of neck pain: Are trajectory patterns stable over a 1-year period?

BACKGROUND

Recent studies with data-driven approaches have established common pain trajectories. It is uncertain whether these trajectory patterns are consistent over time, and if a shorter measurement period will provide accurate trajectories.

METHODS

We included 1,124 patients with non-specific neck pain in chiropractic practice. We classified patients into pre-defined trajectory patterns in each of four quarters of the follow-up year (persistent, episodic, and recovery) based on measures of pain intensity and frequency from weekly SMS. We explored the shifts between patterns and compared patients with stable and shifting patterns on baseline characteristics and clinical findings.

RESULTS

785 (70%) patients were in the same pattern in 1st and 4th quarters. Patients with episodic pattern in the 1st quarter shifted to other patterns more frequently than patients in the other patterns. A stable persistent pattern was associated with reduced function and higher scores on psychosocial factors. There was a decreased frequency of patients classified as persistent pattern (75% to 63%) and an increase of patients in recovery pattern (4% to 15%) throughout the four quarters. The frequency of patients classified as episodic remained relatively stable (21% to 24%).

CONCLUSIONS

We found an overall stability of the persistent pattern, and that episodic patterns have more potential for shifts. Shifts mostly occurred between patterns closest in pain variation. The deviation in pattern distribution compared with previous studies suggests that the duration of measurement periods has an impact on the results of the classification.

SIGNIFICANCE

Having persistent pain and having very minor pain is relatively stable over one year, while episodic pain has more potential for shifts. The duration of measurement periods appears to have an impact on the results of the classification. The given criteria resulted in a reduced frequency of episodic pattern due to shorter measurement periods. Our findings contribute to improved understanding and predicting NP using a combination of patient characteristics and trajectory patterns.

High Intensity Training Is an Effective Modality to Improve Long-Term Disability and Exercise Capacity in Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

Previous research indicates that high intensity training (HIT) is a more effective exercise modality, as opposed to moderate intensity training (MIT), to improve disability and physical performance in persons with chronic nonspecific low back pain (CNSLBP). However, it is unclear how well benefits are maintained after intervention cessation. This study aimed to evaluate the long-term effectiveness of HIT on disability, pain intensity, patient-specific functioning, exercise capacity, and trunk muscle strength, and to compare the long-term effectiveness of HIT with MIT in persons with CNSLBP. Persons with CNSLBP (n = 35) who participated in a randomized controlled trial comparing effects of an HIT versus MIT intervention (24 sessions/12 weeks) were included for evaluation at baseline (PRE), directly after (POST), and six months after program finalization (FU) on disability, pain intensity, exercise capacity, patient-specific functioning, and trunk muscle strength. A general linear model was used to evaluate PRE-FU and POST-FU deltas of these outcome measures in each group (time effects) and differences between HIT and MIT (interaction effects). Ultimately, twenty-nine participants (mean age = 44.1 year) were analysed (HIT:16; MIT:13). Six participants were lost to follow-up. At FU, pain intensity, disability, and patient-specific functioning were maintained at the level of POST (which was significant from PRE, p < 0.05) in both groups. However, HIT led to a greater conservation of lowered disability and improved exercise capacity when compared with MIT (p < 0.05). HIT leads to a greater maintenance of lowered disability and improved exercise capacity when compared to MIT six months after cessation of a 12-week supervised exercise therapy intervention, in persons with CNSLBP.

Is there an interdependence between paraspinal muscle mass and lumbar disc degeneration? A MRI based study at 2520 levels in 504 patients

INTRODUCTION

Low back pain is one of the most common cause for outpatient visits. Though few studies have shown the vital role of paraspinal muscles in lumbar spine pathology, literature is scarce regarding the influence of the paraspinal muscles in disc degeneration. We aimed to analyse the correlation between paraspinal muscles and disc degeneration.

METHODS

This is a Level III Prospective Cohort Study done in MRI of lumbosacral spine in 504 patients at 2520 levels from L1-2 to L5-S1. The parameters assessed were age, Pfirrmann grade for disc degeneration and paraspinal muscle (Multifidus and Erector Spinae) mass assessed by the gross cross sectional area of the muscle.The values and their correlation was analyzed using SPSS software.

RESULTS

The study included a total of 504 patients (231 males and 273 females) with a mean age of 52.00 ± 15.00 (22-80) years. The mean GCSA in cm² of the paraspinal muscles at L1-L2, L2-L3,L3-L4,L4-L5,L5-S1 were 16.177 ± 2.72, 17.275 ± 2.16, 16.900 ± 3.07, 16.800 ± 2.63, 13.426 ± 2.42 respectively. We found that the age of the patient is directly proportional to the disc degeneration and inversely proportional to GCSA of paraspinal muscle. There was a significant negative correlation between disc degeneration and paraspinal muscle mass.

CONCLUSION

We found that the paraspinal muscle mass reduces and Pfirrman's Grade increases as age advances. Also patients with disc degeneration tend to have wasting of paraspinal muscles and vice versa. Hence, strengthening the paraspinal muscles should be emphasised to prevent back pain and to stall the degeneration cascade.

Characteristics of ambulatory spine care visits in the United States, 2009-2016

BACKGROUND

Back pain is a leading reason for seeking care in the United States (US), and is a major cause of morbidity.

OBJECTIVE

To analyze demographic, patient, and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009-2016.

METHODS

Data from the National Ambulatory Medical Care Survey from 2009-2016 were used and were sample weighted.

RESULTS

Most patients presenting for ambulatory spine care were 45-64 years (45%), were most commonly female (56.8%), and private insurance (45%) and Medicare (26%) were most common payors. The percentage of visits for spine care done at a primary care setting was 50.1% in 2009-2010 and 48.3% in 2014-2015. Approximately 15.5% were seen in orthopedic surgery clinics in 2009-2010 and 7.3% in 2015-2016. MRI was utilized in 11.7% in 2009-2010 and 11.0% in 2015-2016. Physical therapy was prescribed in 13.2% and narcotic analgesic medications were prescribed in 36.2% of patients in 2015-2016.

CONCLUSIONS

MRI was used more frequently than guidelines recommended, and physical therapy was less frequently utilized despite evidence. A relatively high use of opiates in treatment of back pain was reported and is concerning. Although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based.

Comparative study of combination therapy with non-steroidal anti inflammatory drugs and different doses of low level laser therapy in acute low back pain

According to various side effects of medication in low back pain, respecting conservative therapy, owing to the widespread use of laser therapy in recent decades, related therapeutic outcomes were different and contradictory. The current study aimed at comparing the effect of non-steroidal drugs and laser therapy with different doses in patients with acute low back pain.

METHODS

The current randomized, placebo-controlled study was conducted on 65 patients randomly assigned to four groups. In group 1(N = 20), only drug therapy and in group 2(N = 15), laser therapy (3 J/cm ²) in addition to medication was administrated to the patients. For group 3(N = 15), a therapeutic plan similar to that of group 2 was given; however, the laser dose was 6 J/cm ². Finally, drug therapy plus placebo laser therapy was applied to group 4(N = 15). Pain was compared among the groups using visual analogue scale and Oswestry low back pain disability questionnaire.

RESULTS

Significant difference between baseline pain scores and those of the weeks 1, 2, 3, and 4 of laser therapy in all intervention groups. Also, the results of the intergroup analyses showed a significant difference between group 1 compared with groups 2 and 3. There was a significant ODI difference between the groups after laser therapy.

CONCLUSION

Findings showed that laser therapy plus drug therapy in comparison with drug therapy alone was a more effective method to relieve pain and disability in patient with acute low back pain; however, evidence to support this finding is still inadequate.

Profile and management of patients with low back pain complaints in a Brazilian Emergency Department: a cross-sectional retrospective study

Objective: To describe the demographic profile and the management of patients with low back pain (LBP) complaints presenting to the Emergency Department (ED) of a Brazilian public hospital. Methods: Retrospective, cross-sectional study using a convenience sample of patients with LBP triaged at the studied ED through the Manchester Triage System along a year. Data were extracted from electronic medical records. LBP presentations were classified as non-traumatic, traumatic, and non-spinal related pain according to the signs and symptoms reported. Data included patients’ demographic profile, pain severity and management (e.g., imaging exams, medication prescription and hospitalization). Results: Data from 2016 patients was analyzed. Most were middle-aged adults (mean age = 40.5years, SD 15.7), female (n = 1043, 51.7%) and presented moderate pain intensity (score range 4 to 7 on the Visual Analogue Scale, n=1,471; 74.1%). Non-traumatic pain (n = 1,016; 50.4%) was the main cause of care-seeking. A total of 36.9% (n = 743) underwent imaging exams and 42.2% (n = 850) received medication. Patients with non-spinal related pain were three times more likely to receive opioid medication (OR = 2.96; 95%CI 2.30 to 3.79). Conclusion: Non-traumatic LBP (i.e., no history of trauma or red flags) was the main cause of LBP care-seeking in a Brazilian ED. Most patients were treated conservatively and without hospitalization. Opioids prescription and imaging exams, although performed on a smaller scale, were still used for of the management of this type of LBP.

Productivity losses among people with back pain and among population-based references: a register-based study in Sweden

OBJECTIVE

Back pain is the leading cause for years lived with disability globally and among the main reasons for sickness absence (SA) and disability pension (DP). The objective of this study was to explore the occurrence of SA and DP and to estimate productivity losses among individuals with back pain compared with among matched population-based references.

DESIGN

Explorative prospective cohort study using register microdata.

PARTICIPANTS AND SETTING

A total of 23 176 people, aged 19-60 years, with a first visit to inpatient or specialised outpatient healthcare for back pain (International Statistical Classification of Diseases and Related Health Problems code M54) in 2010 in Sweden and a matched population-based reference group (n=115 880).

OUTCOMES

Long-term SA (in SA spells >14 days) and DP and productivity losses, measured in € (2018 prices) by multiplying the SA and DP net days by the societal cost of each such day.

RESULTS

In the back-pain group, 42% had SA or DP days; in the reference group, the corresponding proportion was 15%. Productivity loss per patient with back pain was €8928 during the 12-month follow-up period; in the reference group, it was €3499 (p<0.0001).

CONCLUSIONS

SA and DP, leading to excess productivity losses among people with back pain, reflect the challenges these patients are facing to maintain their work capacity. Interventions to promote that individuals with back pain remain in paid work should be a priority in order to address the high costs.

The Clinical and Cost-Effectiveness of Telerehabilitation for People With Nonspecific Chronic Low Back Pain: Randomized Controlled Trial

BACKGROUND

Telerehabilitation can facilitate multidisciplinary management for people with nonspecific chronic low back pain (NCLBP). It provides health care access to individuals who are physically and economically disadvantaged.

OBJECTIVE

This study aimed to evaluate the clinical and cost-effectiveness of telerehabilitation compared with a clinic-based intervention for people with NCLBP in Nigeria.

METHODS

A cost-utility analysis alongside a randomized controlled trial from a health care perspective was conducted. Patients with NCLBP were assigned to either telerehabilitation-based McKenzie therapy (TBMT) or clinic-based McKenzie therapy (CBMT). Interventions were carried out 3 times weekly for a period of 8 weeks. Patients' level of disability was measured using the Oswestry Disability Index (ODI) at baseline, week 4, and week 8. To estimate the health-related quality of life of the patients, the ODI was mapped to the short-form six dimensions instrument to generate quality-adjusted life years (QALYs). Health care resource use and costs were assessed based on the McKenzie extension protocol in Nigeria in 2019. Descriptive and inferential data analyses were also performed to assess the clinical effectiveness of the interventions. Bootstrapping was conducted to generate the point estimate of the incremental cost-effectiveness ratio (ICER).

RESULTS

A total of 47 patients (TBMT, n=21 and CBMT, n=26), with a mean age of 47 (SD 11.6) years for telerehabilitation and 50 (SD 10.7) years for the clinic-based intervention, participated in this study. The mean cost estimates of TBMT and CBMT interventions per person were 22,200 naira (US $61.7) and 38,200 naira (US $106), respectively. QALY gained was 0.085 for TBMT and 0.084 for CBMT. The TBMT arm was associated with an additional 0.001 QALY (95% CI 0.001 to 0.002) per participant compared with the CBMT arm. Thus, the ICER showed that the TBMT arm was less costly and more effective than the CBMT arm.

CONCLUSIONS

The findings of the study suggested that telerehabilitation for people with NCLBP was cost saving. Given the small number of participants in this study, further examination of effects and costs of the interventions is needed within a larger sample size. In addition, future studies are required to assess the cost-effectiveness of this intervention in the long term from the patient and societal perspective.

Task-Specific Sensitivity in Physical Function Testing Predicts Outcome in Patients With Low Back Pain

OBJECTIVE

To investigate the prognostic value of task-specific sensitivity in patients with low back pain by exploring whether task-specific sensitivity during physical function testing was associated with self-reported change in pain and disability.

DESIGN

Prospective cohort study nested in a randomized controlled trial.

METHODS

The study included 260 patients with low back pain, referred for evaluation in a secondary care setting. All patients completed questionnaires and underwent clinical examination by a physical therapist. Patients rated their pain intensity before and after completing a test battery measuring physical function and were classified into 4 categories-worse, unchanged, better, or no pain-depending on their pain response. At 3-month follow-up, outcomes were obtained by a postal questionnaire.

RESULTS

Task-specific sensitivity significantly predicted pain, after adjusting for known prognostic factors. Patients in the no pain, better, and unchanged groups improved their pain score significantly more than patients in the worse pain group. Patients in the no pain group also improved their disability score significantly more compared to patients in the worse pain group, after adjusting for known prognostic factors.

CONCLUSION

Task-specific sensitivity predicted pain intensity after 3 months in patients with low back pain. The prognostic value appears limited with respect to disability. J Orthop Sports Phys Ther 2020;50(4):206-213. Epub 30 Oct 2019. doi:10.2519/jospt.2020.8953.

The prognostic merit of self-reported triggers of recurrent low back pain: study protocol

Background

Most cases of low back pain (LBP) are regarded as non-specific and current studies indicate that for many this is a chronic recurrent condition, in which people experience episodes of pain with symptom-free periods in between. It is likely that acute exposure to some factors triggers the reappearance of new episodes in recurrent LBP regardless of the causality of the underlying condition (i.e. risk factors). Additionally, it has been shown that LBP patients present with different trajectories and different trajectories possibly have different triggers. Hence, dividing patients into some clinically meaningful subgroups may offer new insights into triggers, effective preventive strategies and, therefore, prognosis. This study aims to identify self-reported triggers and trajectories of episodes of recurrent LBP and to examine the prognostic association between different triggers and LBP trajectories.

Methods

This is a longitudinal, multicentre, Australia-wide observational study of patients with recurrent non-specific LBP. Two hundred adults with at least a one-year history of LBP will be recruited from primary care clinics or private practices and followed for a year. Each will receive an SMS every fortnight (26 time-points in total) enquiring the occurrence of a new episode of pain in the past 2 weeks and its intensity. Upon report of a new episode, a telephone interview will be performed to appraise exposure to self-nominated triggers in a period of 24 h preceding the pain. Trajectories will be identified by latent class analysis at the end of the follow-up based on the pain intensity, frequency, and length of episodes. Triggers will be categorised into physical and psychosocial groups. Generalised linear mixed models with logit links will be used to explore pain triggers associated with pain trajectories.

Discussion

The completion of this study will provide insight into the patients' self-reported triggers of LBP and also their possible prognostic association with different trajectories. Some newly-identified and pre-identified triggers are likely to be found and reported.

Determinants Of Patient Experience With Low Back Pain Interdisciplinary Care: A Pre-Post Interventional Study

Background and purpose

Measuring patients’ experiences of health services has become an essential part of quality of care reporting and a means for identifying opportunities for improvement. This study aimed to evaluate change in patient experience in an interdisciplinary primary care program and to estimate the impact on patient experience of sociodemographic, function, pain and general health status, resource utilization, and process variables.

Patients and methods

A 6-month interdisciplinary care program for individuals with low back pain (LBP) was implemented at four primary care settings and evaluated using an observational pre/post study design. The change in patient experience was evaluated using the Patient Assessment of Chronic Illness Care questionnaire (PACIC) completed at baseline and 6 months post-intervention (n=132). Descriptive and multivariable analyses were performed using SAS version 9.3.

Results

The average patient age was 57 (SD: 14) years of age and the majority were female (53%). The mean overall PACIC score was 2.6 (SD: 1.1) at baseline and 3.6 (SD: 0.9) at 6 months. The experience of care improved for 62% of the participants based on the minimal clinically important difference (MCID). No significant determinants of overall PACIC change score were identified in the multivariable regression models.

Conclusion

The lack of association of hypothesized determinants requires further examination of the properties of the PACIC and with a larger sample. Future investigation is needed on the relationship between improved patient experience and outcomes.

Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks

STUDY DESIGN

A prospective observational study.

OBJECTIVE

To externally validate the prediction model developed by Schellingerhout and colleagues predicting global perceived effect at 12 weeks in patients with neck pain and to update and internally validate the updated model.

SUMMARY OF BACKGROUND DATA

Only one prediction model for neck pain has undergone some external validation with good promise. However, the model needs testing in other populations before implementation in clinical practice.

METHODS

Patients with neck pain (n = 773) consulting Norwegian chiropractors were followed for 12 weeks. Parameters from the original prediction model were applied to this sample for external validation. Subsequently, two random samples were drawn from the full study sample. One sample (n = 436) was used to update the model; by recalibration, removing noninformative covariates, and adding new possible predictors. The updated model was tested in the other sample (n = 303) using stepwise logistic regression analysis. Main outcomes for performance of models were discrimination and calibration plots.

RESULTS

Three hundred seventy patients (47%) in the full study sample reported persistent pain at 12 weeks. The performance of the original model was poor, area under the receiver operating characteristics curve was 0.55 with a Confidence Interval of 0.51-0.59. The updated model included Radiating pain to shoulder and/or elbow, education level, physical activity, consultation-type (first- time, follow-up or maintenance consultation), expected course of neck pain, previous course of neck pain, number of pain sites, and the interaction term Physical activity##Number of pain sites. The area under the receiver operating characteristics curve was 0.65 with a 95% Confidence Interval of 0.58-0.71 for the updated model.

CONCLUSION

The predictive accuracy of the original model performed insufficiently in the sample of patients from Norwegian chiropractors and the model is therefore not recommended for that setting. Only one predictor from the original model was retained in the updated model, which demonstrated reasonable good performance predicting outcome at 12 weeks. Before considering clinical use, a new external validation is required.

LEVEL OF EVIDENCE

3.

Transitioning from acute to chronic pain: a simulation study of trajectories of low back pain

Background

Identifying how pain transitions from acute to chronic is critical in designing effective prevention and management techniques for patients’ well-being, physically, psychosocially, and financially. There is an increasingly pressing need for a quantitative and predictive method to evaluate how low back pain trajectories are classified and, subsequently, how we can more effectively intervene during these progression stages.

Methods

In order to better understand pain mechanisms, we investigated, using computational modeling, how best to describe pain trajectories by developing a platform by which we studied the transition of acute chronic pain.

Results

The present study uses a computational neuroscience-based method to conduct such trajectory research, motivated by the use of hypothalamic–pituitary–adrenal (HPA) axis activity-history over a time-period as a way to mimic pain trajectories. A numerical simulation study is presented as a “proof of concept” for this modeling approach.

Conclusions

This model and its simulation results have highlighted the feasibility and the potential of developing such a broader model for patient evaluations.

Pubertal development and growth are prospectively associated with spinal pain in young people (CHAMPS study-DK)

PURPOSE

To examine the prospective associations of pubertal development and linear growth with spinal pain frequency and duration in children.

METHODS

We recruited students from 10 public primary schools. Over 42 months, pubertal development was assessed four times and categorized according to Tanner stages 1-5, and height was measured on seven occasions. Occurrences of spinal pain were reported weekly via text messaging. We constructed variables for spinal pain duration (total weeks with pain) and frequency (number of episodes). Potential associations between pubertal development and growth were examined with generalized estimating equations and reported with incident rate ratios (IRRs). All models were adjusted for potential confounders.

RESULTS

Data from 1021 children (53% female; mean [SD] age = 9.4 [1.4] years), with median participation duration of 39 months, were included. Advancing pubertal development was associated with increased spinal pain duration (IRR [95% CI] = 1.90 [1.45, 2.49] to 5.78 [4.03, 8.29]) and frequency of pain episodes (IRR [95% CI] = 1.32 [1.07, 1.65] to 2.99 [2.24, 3.98]). Similar associations were observed for each 1-cm change in height in 6 months with spinal pain duration (IRR [95% CI] = 1.19 [1.15, 1.23]) and frequency (IRR [95% CI] = 1.14 [1.11, 1.17]). The relations between pubertal development and spinal pain, as well as growth and spinal pain, were largely independent.

CONCLUSIONS

In young people, pubertal development and linear growth are likely to be independent risk factors for the development of spinal pain. Pubertal development demonstrates evidence of dose-response in its relationship with spinal pain. This knowledge may assist healthcare providers with clinical decision-making when caring for pediatric patients. These slides can be retrieved under Electronic Supplementary Material.

Low back pain among primary school teachers in Rural Kenya: Prevalence and contributing factors

Background

Low back pain (LBP) has been recognised as a common occupational problem with a high prevalence among work-related musculoskeletal disorders. Although there appears to be a high prevalence of LBP among school teachers, there is inadequate information on the prevalence and predisposing factors of LBP among primary school teachers in rural Western Kenya.

Aim

To determine the prevalence, factors associated with LBP and physical disability caused by LBP.

Setting

The setting was public schools in rural Western Kenya selected by simple random sampling method.

Methods

A cross-sectional study was conducted among primary teachers from public schools using a self-administered questionnaire. The questionnaire included information on LBP, demographic data, occupational and psychosocial factors and disability score. The 12-month prevalence, associated factors and LBP disability were analysed.

Results

The 12-month self-reported prevalence of LBP among primary teachers was 64.98%, with close to 70% of them reporting minimal disability. The logistic regression analysis showed that female gender (odds ratio [OR]: 1.692, p < 0.02) was associated with LBP and high supervisor support (OR: 0.46, p < 0.003) was negatively associated with LBP.

Conclusion

The prevalence of LBP among primary school teachers in rural Western Kenya is 64.98%, with the majority of them reporting minimal disability. The identified risk factors were female gender and low supervisor support. The presence of work-related psychosocial risk factors in this study suggests a comprehensive approach in evaluation and management of LBP. Preventive measures should be in place to prevent and reduce the progression of LBP disability.

Keywords

low back pain; rural; Kenya; teachers, primary school; public schools; risk factors; disability.

Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up

Supplemental Digital Content is Available in the Text.

Low back pain trajectories identified previously appear generalizable. Effective management tailored to individual trajectories needs to be identified.

Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in 1 primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was conducted on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-year follow-up plus at least 3 (of 6) subsequent monthly questionnaires. Baseline factors were measured using validated tools. Pain intensity scores from the 5-year follow-up and monthly questionnaires were used to assign participants into 4 previously derived pain trajectories (no or occasional mild, persistent mild, fluctuating, and persistent severe), using latent class analysis. Posterior probabilities of belonging to each cluster were estimated for each participant. The posterior probabilities for the assigned clusters were very high (>0.90) for each cluster except for the smallest “fluctuating” cluster (0.74). Lower social class and higher pain intensity were significantly associated with a more severe trajectory 5 years later, as were patients' perceptions of the greater consequences and longer duration of pain, and greater passive behavioural coping. Low back pain trajectories identified previously appear generalizable. These allow better understanding of the long-term course of LBP, and effective management tailored to individual trajectories needs to be identified.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Comparing satisfaction with a participatory driven web-application and a standard website for patients with low back pain: a study protocol for a randomised controlled trial (part of the ADVIN Back Trial)

Background

Low back pain (LBP) is the most common musculoskeletal disorder and a leading cause of disability worldwide. It impacts daily life and work capacity and is the most common reason for consulting a general practitioner (GP). According to international guidelines, information, reassurance, and advice are key components in the management of people with LBP; however, the consultation time available in general practice for each patient is often limited. Therefore, new methods to support the delivery of information and advice are needed and online technologies provide new opportunities to extend the consultation beyond the GP’s office. However, it is not known whether GPs and people consulting their GP because of LBP will accept online technologies as part of the consultation. By involving patients in the development of online information, we may produce more user-friendly content and design, and improve patient acceptance and usage, optimising satisfaction and clinical outcomes. The purpose is to study satisfaction in people consulting their GP with LBP depending on whether they are randomised to receive supporting information through a new participant-driven web application or a standard reference website containing guideline-based information on LBP. It is hypothesised that patients offered information in a new web application will be more satisfied with the online information after 12 weeks compared to patients allocated to a standard website.

Methods

Two hundred patients with LBP aged ≥ 18 years consulting Danish general practice will be randomly allocated 1:1 to either the new web application or standard online information in permuted blocks of two, four, and six. Patients with serious spinal diseases (cancer, fractures, spinal stenosis, spondyloarthritis), those without Danish reading skills or without online access, and pregnant women will not be included in the trial. Patient satisfaction measured by the Net Promotor Score after 12 weeks is the primary outcome. Patients will be aware of their allocation. GPs will be blinded unless informed by the patient. Assessors are blinded.

Discussion

To our knowledge, this is the first trial evaluating whether involving LBP patients in the development of an online web application will result in higher patient satisfaction.

Trial registration

ClinicalTrials.gov NCT03088774. Registered on 23 March 2017. Last updated on 14 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2795-0) contains supplementary material, which is available to authorized users.

What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Transitioning from Acute to Chronic Pain: An Examination of Different Trajectories of Low-Back Pain

Traditionally, there has been a widely accepted notion that the transition from acute to chronic pain follows a linear trajectory, where an injury leads to acute episodes, subacute stages, and progresses to a chronic pain condition. However, it appears that pain progression is much more complicated and individualized than this original unsupported assumption. It is now becoming apparent that, while this linear progression may occur, it is not the only path that pain, specifically low-back pain, follows. It is clear there is a definite need to evaluate how low-back pain trajectories are classified and, subsequently, how we can more effectively intervene during these progression stages. In order to better understand and manage pain conditions, we must examine the different pain trajectories, and develop a standard by which to use these classifications, so that clinicians can better identify and predict patient-needs and customize treatments for maximum efficacy. The present article examines the most recent trajectory research, and highlights the importance of developing a broader model for patient evaluation.

Preferences for Web-Based Information Material for Low Back Pain: Qualitative Interview Study on People Consulting a General Practitioner

Background

Information on self-management, including addressing people’s fears and concerns, are core aspects of managing patients with low back pain (LBP). Web apps with patient information may be used to extend patient-physician consultations and encourage self-management outside of the consultation room. It is, however, important to identify the end users’ needs and preferences in order to maximize acceptance.

Objective

The aim of this study was to identify preferences for the content, design, and functionality of a Web app with evidence-based information and advice for people with LBP in Denmark.

Methods

This is a phenomenological qualitative study. Adults who had consulted their general practitioner because of LBP within the past 14 days were included. Each participated in a semistructured interview, which was audiotaped and transcribed for text condensation. Interviews were conducted at the participant’s home by 2 interviewers. Participants also completed a questionnaire that requested information on age, gender, internet usage, interest in searching new knowledge, LBP-related function, and pain.

Results

Fifteen 45-min interviews were conducted. Participants had a median age of 40 years (range 22-68 years) and reported a median disability of 7 points (range 0-18) using the 23-item Roland Morris Disability Questionnaire. Participants reported that Web-based information should be easy to find and read, easily overviewed, and not be overloaded with information. Subjects found existing Web-based information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies or organizations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy and preferred site when searching for information and advice regarding LBP.

Conclusions

This study identified important issues to consider when developing and supplementing existing general practice treatment with Web-based information and advice for patients with LBP. Development of a Web app should consider patient input, and developers should carefully address the following domains: readability, customization, design, credibility, and usability.

Failure to define low back pain as a disease or an episode renders research on causality unsuitable: results of a systematic review

Background

Causative factors may be different for the very first onset of symptoms of the ‘disease’ of low back pain (LBP) than for ensuing episodes that occur after a pain-free period. This differentiation hinges on a life-time absence of low back pain at first onset and short-term absence for further episodes. In this systematic review, we explored whether researchers make these distinctions when investigating the causality of LBP.

Methods

A literature search of PUBMED, CINAHL, and SCOPUS databases was performed from January 2010 until September 2016 using the search terms ‘low back pain’ or ‘back pain’ and ‘risk factor’ or ‘caus*’ or ‘predict*’ or ‘onset’ or ‘first-time’ or ‘inception’ or ‘incidence’. Two reviewers extracted information on study design, types of episodes of back pain to distinguish the disease of LBP and recurring episodes, and also to determine the definitions of disease- or pain-free periods.

Results

Thirty-three articles purporting to study causes of LBP were included. Upon scrutiny, 31 of the 33 articles were unclear as to what type of causality they were studying, that of the ‘disease’ or the episode, or a mere association with LBP. Only 9 studies used a prospective study design. Five studies appeared to investigate the onset of the disease of LBP, however, only one study truly captured the first incidence of LBP, which was the result of sports injury. Six appeared to study episodes but only one clearly related to the concept of episodes. Therefore, among those 11 studies, nine included both first-time LBP and episodes of LBP. Consequently, 22 studies related to the prevalence of LBP, as they probably included a mixture of first-time, recurring and ongoing episodes without distinction.

Conclusion

Recent literature concerning the causality of LBP does not differentiate between the ‘disease’ of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, current research is not capable of providing a valid answer on this topic.

The Effectiveness and Safety of Manual Therapy on Pain and Disability in Older Persons With Chronic Low Back Pain: A Systematic Review

OBJECTIVES

The aim of this study was to perform a systematic review of the literature of the effectiveness and safety of manual therapy interventions on pain and disability in older persons with chronic low back pain (LBP).

METHODS

A literature search of 4 electronic databases was performed (PubMed, EMBASE, OVID, and CINAHL). Inclusion criteria included randomized controlled trials of manual therapy interventions on older persons who had chronic LBP. Effectiveness was determined by extracting and examining outcomes for pain and disability, with safety determined by the report of adverse events. The PEDro scale was used for quality assessment of eligible studies.

RESULTS

The search identified 405 articles, and 38 full-text articles were assessed. Four studies met the inclusion criteria. All trials were of good methodologic quality and had a low risk of bias. The included studies provided moderate evidence supporting the use of manual therapy to reduce pain levels and alleviate disability.

CONCLUSIONS

A limited number of studies have investigated the effectiveness and safety of manual therapy in the management of older people with chronic LBP. The current evidence to make firm clinical recommendations is limited. Research with appropriately designed trials to investigate the effectiveness and safety of manual therapy interventions in older persons with chronic LBP is required.

Validity of the Visual Trajectories Questionnaire for Pain

•

There is growing clinical/research interest in longitudinal patient pain trajectories.

•

Validity of a self-report trajectories question was tested in a back pain population.

•

Self-report trajectories were compared with derived longitudinal trajectories.

•

Acceptable validity is reported of a new self-report measure of trajectories.

Researchers have identified trajectories of pain derived using statistical techniques on longitudinal data. These trajectories have potential to be of use clinically but the repeated data collection required is currently impractical for such situations. Our aim was to investigate the validity of a self-report (Visual Trajectories Questionnaire-Pain) for pain. Analysis included participants from 2 prospective cohorts of people seeking primary health care for back pain (n = 622). A question was developed asking people to classify their pain experience into one of a number of trajectories using visual and word descriptions. Overall 98% of participants completed the question; criterion validity was established by comparing self-report trajectories and trajectories derived using longitudinal latent class analysis, and construct validity was established by comparing responses to the questionnaire against an existing model of back pain stages. As expected variables such as pain intensity and widespreadness, other symptoms, and psychological distress showed an increasing trend of severity across trajectory categories in line with the hypothesized model. In conclusion, the self-report single-item Visual Trajectories Questionnaire-Pain is acceptable to patients and supported by evidence of face, criterion, and construct validity. Further research is needed to investigate the clinical usefulness of the question.

Perspective

This study provides a new questionnaire (Visual Trajectories Questionnaire-Pain) that captures the longitudinal state of a patient's pain experience. The Visual Trajectories Questionnaire-Pain has shown aspects of face, criterion, and construct validity, and has the potential to be clinically useful.

Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain

Background

Low back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.

Method

Adult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.

Results

The study comprised 1271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.

Conclusion

The QTFC identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals’ outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1495-3) contains supplementary material, which is available to authorized users.

Individual courses of low back pain in adult Danes: a cohort study with 4-year and 8-year follow-up

Background

Few longitudinal studies have described the variation in LBP and its impact over time at an individual level. The aims of this study were to: 1) determine the prevalence of LBP in three surveys over a 9-year period in the Danish general population, using five different definitions of LBP, 2) study their individual long-term courses, and 3) determine the odds of reporting subsequent LBP when having reported previous LBP.

Methods

A cohort of 625 men and women aged 40 was sampled from the general population. Questions about LBP were asked at ages 41, 45 and 49, enabling individual courses to be tracked across five different definitions of LBP. Results were reported as percentages and the prognostic influence on future LBP was reported as odds ratios (OR).

Results

Questionnaires were completed by 412 (66%), 348 (56%) and 293 (47%) persons respectively at each survey. Of these, 293 (47%) completed all three surveys. The prevalence of LBP did not change significantly over time for any LBP past year: 69, 68, 70%; any LBP past month: 42, 48, 41%; >30 days LBP past year: 25, 27, 24%; seeking care for LBP past year: 28, 30, 36%; and non-trivial LBP, i.e. LBP >30 days past year including consequences: 18, 20, 20%. For LBP past year, 2/3 remained in this category, whereas four out of ten remained over the three time-points for the other definitions of LBP. Reporting LBP defined in any of these ways significantly increased the odds for the same type of LBP 4 years later. For those with the same definition of LBP at both 41 and 45 years, the risk of also reporting the same at 49 years was even higher, regardless of definition, and most strongly for seeking care and non-trivial LBP (OR 17.6 and 18.4) but less than 11% were in these groups.

Conclusion

The prevalence rates of LBP, when defined in a number of ways, were constant over time at a group level, but did not necessarily involve the same individuals. Reporting more severe LBP indicated a higher risk of also reporting future LBP but less than 11% were in these categories at each survey.

Differences among primary care patients with different mechanical patterns of low back pain: a cross-sectional investigation

OBJECTIVES

To characterise and compare a persistent low back pain (LBP) population based on 4 clinical pain patterns.

DESIGN

Cross-sectional analysis of patient-reported data.

SETTING

Patients from 220 primary care practitioners in 3 cities in Ontario, Canada.

PARTICIPANTS

1020 individuals seeking LBP care.

INCLUSION CRITERIA

LBP symptoms lasting 1½-12 months, or unmanageable recurrent symptoms; ages 18+years.

EXCLUSION CRITERIA

pregnant/1-year postpartum; involved in active litigation or motor vehicle injury; emergent spinal presentations; pain disorder diagnosis; work injury claim; or constant symptoms persisting >12 months postonset.

MAIN OUTCOME MEASURE

Hall pain pattern subgroups: back dominant pain aggravated by flexion (P1) or extension (P2), or leg dominant constant (P3) or intermittent (P4) pain (multinomial logistic outcome; referent: P1).

RESULTS

Groups P1 and P2 had the highest proportion of women. P2 and P4 had higher mean ages and comorbidity counts. P3 and P4 had higher proportions of overweight/obese individuals and lower general health scores. Adjusted models: being male and overweight/obese was associated with increased odds of being in P3 (OR 1.64 (95% CI 1.10 to 2.46), and OR 1.74 (1.13 to 2.68), respectively) and P4 (OR 1.87 (1.11 to 3.15) and OR 1.91 (1.06 to 3.42), respectively), and increasing age with increased odds of being in P2 (OR 1.02 (1.01 to 1.03)) and P4 (OR 1.06 (1.04 to 1.08)). Increasing comorbidity count was associated with increased odds of being in P2 (OR 1.14 (1.0 to 1.3)), and better general health scores with decreased odds of being in P3 (OR 0.40 (0.18 to 0.93)).

CONCLUSIONS

This is the first study to examine the 'Hall system' in a non-rehab primary care population. Subgroups classified according to this system appear to have distinct profiles. Further research is needed to better characterise and determine the prognostic implication of these clinically derived subgroups.

A proposal for the organization of the referral of patients with chronicnon-specific low back pain

Low back pain in general and specifically chronic low back pain forms a major burden for the patient and society. Recently studies demonstrated that up to 65% of patients evolve to chronic pain as opposed to the previously accepted 8%. As low back pain patients present first with their general practitioner, the latter should establish a treatment plan, including the appropriate referrals. There are, however, no clear guidelines as to how to refer low back pain patients. The process of trial and error of different specialties and treatment possibilities often results in a long and costly trajectory. A better understanding of the subtypes of chronic low back pain, the risks for chronification and fast adequate referral may result in higher patient satisfaction and cost reduction. Proposed solutions: We propose a classification system based on the clinical and anatomical characteristics of axial low back pain, separated from radicular pain. It is important to recognize the risks for chronification, such as degenerative and/or herniated disk, a smaller cross-sectional area of the multifidus, erector spinae, and psoas muscles and psychological and social factors, to be able to provide appropriate management. Also stratification of the patients according to the degree of disability may help in defining the correct treatment approach. A one-and-a-half line approach, where a spine physician assistant works under the supervision of the general practitioner to establish the sub-diagnosis, the risk factors for chronicity and to explain the proposed management plan to the patient, may be helpful for an early appropriate treatment selection for the patient with chronic low back pain.

Revisiting the Corticomotor Plasticity in Low Back Pain: Challenges and Perspectives

Chronic low back pain (CLBP) is a recurrent debilitating condition that costs billions to society. Refractoriness to conventional treatment, lack of improvement, and associated movement disorders could be related to the extensive brain plasticity present in this condition, especially in the sensorimotor cortices. This narrative review on corticomotor plasticity in CLBP will try to delineate how interventions such as training and neuromodulation can improve the condition. The review recommends subgrouping classification in CLBP owing to brain plasticity markers with a view of better understanding and treating this complex condition.

Influence of paravertebral muscles training on brain plasticity and postural control in chronic low back pain

BACKGROUND AND PURPOSE

Isometric activation (ISOM) of deep multifidi muscles (MF) can influence postural adjustments and primary motor cortex (M1) function in chronic low back pain (CLBP). In order to better understand how ISOM impacts on CLBP condition, the present study contrasted ISOM after-effects on M1 function, MF postural activation and pain with another training, the global activation of paravertebral muscles (GLOB, hip extension). The main objective of this study was to compare the effects of ISOM and GLOB (3-week training each) on MF postural activation and M1 function in a CLBP population.

METHODS

Twenty-four people with CLBP were randomly allocated to ISOM and GLOB groups for a 3-week daily practice. Pre/post-training after-effects were assessed by the onset of superficial MF (MF-S) activation during ballistic limb movements (bilateral shoulder flexion in standing; unilateral hip extension in prine lying), MF-S corticomotor control tested by transcranial magnetic stimulation of M1, and assessment of pain, kinesiophobia and disability by standardized questionnaires.

RESULTS

Both ISOM and GLOB improved pain and disability. However, only ISOM influenced M1 function (decreased corticospinal excitability and increased intracortical inhibition), fastened MF-S postural activation and decreased kinesiophobia.

CONCLUSIONS

Changes of corticospinal excitability and of MF-S postural adjustments suggest that ISOM better influenced brain plasticity. Future studies should further test whether our novel findings relate to an influence of the exercises on the lumbopelvic control of different muscles and on cognitive function. Clinically, individual's evaluation remains warranted before prescribing one or the other of these two conventional exercises for reducing pain.

IMPLICATIONS

This original study presents how motor control exercises can influence brain plasticity and postural control in chronic low back pain. This knowledge will impact on the decision of clinicians to prescribe specific exercises with a view of improving motor control in this musculoskeletal condition.

Neuromuscular exercise and back counselling for female nursing personnel with recurrent non-specific low back pain: study protocol of a randomised controlled trial (NURSE-RCT)

Introduction

Nursing personnel have high risk for incidence of low back pain (LBP) followed by development of chronic pain and disability. Multiple risk factors such as patient handling, night shift work and lack of supporting work culture have been identified. In subacute LBP, high-fear avoidance is prognostic for more pain, disability and not returning to work. Lack of leisure-time physical activity predicts long-term sickness absence. The purpose of this study is to compare effectiveness of 6-month neuromuscular exercise and counselling in treating back pain in female nursing personnel with recurrent non-specific LBP pain compared with either (exercise or counselling) alone and a non-treatment control group.

Methods and analysis

The design is of a double-blinded four-arm randomised controlled trial with cost-effectiveness evaluation at 12 and 24 months. The study is conducted in 3 consecutive substudies. The main eligibility criteria are experience of LBP during the past 4 weeks with intensity of at least 2 (Numeric Rating Scale 0–10) and engagement in patient handling. Sample size was estimated for the primary outcome of pain intensity (visual analogue scale). Study measurements are outlined according to the model of International Classification of Functioning, Disability and Health, which incorporates the biopsychosocial processes assessed.

Ethics and dissemination

This study is carried out conforming to the guidelines of good scientific practice and provisions of the declaration of Helsinki. Increasing physical and mental capacity with interventions taking place immediately after working hours near the worksite may reduce development of chronic LBP and work disability in female nursing personnel with recurrent non-specific LBP.

Trial registration number

NCT04165698.

Persistence of pain in patients with chronic low back pain reported via weekly automated text messages over one year

Background

A previous study has suggested that it is uncommon for patients with chronic bothersome low back pain (LBP), who consult the secondary health care sector, to report at least four consecutive weeks without such bothersome pain in 1 year. It is not yet known, however, how many days of the week they experience pain throughout the year.

Method

The current study analyzed data collected in two randomized clinical studies conducted in 2007–9 on patients with back pain (Study 1 and 2). Study participants were patients with LBP for more than 2 months, one group with MRI-defined Modic changes (Study 1) and the other without any pathological explanation for the pain (Study 2). In both studies, participants were followed over 1 year with weekly automated text messages (SMS-Track). Each week they reported the number of days they had experienced bothersome LBP (0–7 days). The number of weeks with 7 days of bothersome LBP was calculated for both study groups. As baseline and outcome characteristics were similar between the intervention and control groups in each study, the data from treatment and control groups in each study were analyzed together, regardless of treatment allocation and the results compared between the two study samples.

Results

The proportion of patients reporting bothersome LBP all days of the week ranged from 0 to 100 %, with the findings arranged in a U-shaped curve. The pain frequency patterns were remarkably similar for the two study samples. At one extreme, 31 % of participants reported 0–10 % of weeks with daily LBP. At the other extreme, 25 % of participants reported 91–100 % of weeks with daily LBP. The distribution between these values was also very similar for the two groups.

Conclusion

This study revealed there to be considerable variation in weekly persistence of symptoms during 1 year in patients from the secondary care sector with chronic LBP. The results range from bothersome pain each day of the week, every week of the year, to no weeks at all with 7 days of pain. Interestingly, this pattern is near-identical in the two study samples; those with non-specific LBP and those with LBP and Modic changes. This heterogeneic pain profile in patients with chronic LBP deserves to be further investigated.

Chronic low back pain clinical outcomes present higher associations with the STarT Back Screening Tool than with physiologic measures: a 12-month cohort study

BACKGROUND

Stratification strategies based on identifying patient's prognosis in order to guide patient care constitute one of the most prominent and recent approach in low back pain research. The STarT Back Screening Tool (SBST) although promising, has not been studied in patients with chronic low back pain (cLBP). Considering how challenging it is to translate research into practice, the value of integrating a new tool should be thoroughly assessed. The purpose was therefore to assess associations between the short- and long-terms clinical status and two types of variables, physiologic measures and the SBST, in participants with cLBP. The ability of both types of variables to discriminate between participants with and without higher levels of disability, pain, fear of movement and patient's global impression of change was also investigated.

METHODS

Fifty-three volunteers with cLBP participated in an initial evaluation and follow-ups at 2-, 4-, 6- and 12-month. Physiologic measures (maximal voluntary contraction, maximal endurance and muscle activity evaluated during prone and lateral isometric tasks) and the SBST were assessed at baseline. Disability (Oswestry Disability Index, ODI), pain intensity (101-point Numerical Rating Scale, NRS), fear of movement (Tampa Scale for Kinesiophobia, TSK) and patient's global impression of change (7-point scale, PGIC) were evaluated at baseline and at each follow-up. Aside the use of correlation analyses to assess potential associations; ROC curves were performed to evaluate the discriminative ability of physiologic measures and the SBST.

RESULTS

The SBST allowed for the identification of participants presenting higher levels of disability (ODI ≥24 %), pain (NRS ≥37 %) or fear of movement (TSK ≥41/68) over a 12-month period (AUC = 0.71 to 0.84, ps < 0.05). The SBST score was also correlated with disability at each follow-up (τ = 0.22 to 0.33, ps < 0.05) and with pain intensity and fear of movement at follow-ups. Among physiologic measures, only maximal voluntary contraction was correlated to disability, pain intensity or fear of movement during the follow-up (|τ| = 0.26 to 0.32, ps < 0.05) and none was able to identify participants presenting higher levels of outcomes (AUC ps > 0.05).

CONCLUSION

Physiologic measures obtained during prone and lateral tests have limited associations with the clinical status over a 12-month period in patients with nonspecific chronic low back pain. On the other hand, the STarT Back Screening Tool is useful for the identification of patients who will present higher levels of disability, pain intensity and fear of movement over a year.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02226692.