Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Confidence in providing primary care to patients with low back pain among physiotherapists

BACKGROUND

Low back pain (LBP) is a common musculoskeletal disorder with distinct clinical features. Direct access to physiotherapy (PT), with physiotherapists (PTs) acting as primary care providers, can improve the management of individuals with LBP. However, clinician confidence may affect their willingness to provide primary care as well as their performance as primary care providers. The objectives of this study were: (1) to develop the Primary Care Confidence Scale (PCCS), and (2) to evaluate PTs' confidence in managing LBP in primary care.

METHODS

The PCCS questionnaire was developed through a seven-stage Delphi process involving experts who modified an existing self-confidence scale. The questionnaire was completed by 314 PTs, 140 of whom completed it again after 2 weeks. Structural validity was evaluated using exploratory and confirmatory factor analysis. Reliability was assessed with Cronbach's alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Spearman tests assessed correlations between background characteristics and PCCS scores. Two independent t-tests estimated the effects of gender and post-graduate education. One-way ANOVA was used to evaluate the impact of the workplace.

RESULTS

The PCCS had a multidimensional structure with three factors demonstrating an acceptable model fit and good reliability (α = 0.83, ICC = 0.78). The mean confidence level was 75% (PCCS = 45 ± 6/60), with moderate positive correlations observed between PCCS scores and both age (r = 0.42, p < 0.001) and years of experience (r = 0.33, p < 0.001). PTs working in public or private outpatient clinics had significantly higher scores (PCCS = 45.3 and 47.0, respectively) compared to PTs working in an inpatient hospital or in rehabilitation centers (PCCS = 40.6 and 40.3, respectively, p < 0.009).

CONCLUSIONS

The newly developed PCCS demonstrated adequate validity and high reliability, suggesting that it is suitable for measuring confidence in treating patients with LBP in primary care settings. PTs demonstrated confidence levels indicative of their perception to manage patients in primary care. Health policy makers and educators could incorporate the PCCS into training and evaluation programs to assess clinicians' confidence and perceived readiness to treat LBP in primary care.

Inequities in Physical Therapy Receipt of US Service Members and Veterans With Low Back Pain

OBJECTIVE

To investigate inequities in time to physical therapy (PT) for patients with low back pain (LBP).

DESIGN

Retrospective observational study using data from the Department of Defense and Veterans Health Administration clinical and administrative data repositories derived from medical records, claims, and enrolment data.

SETTING

Military Health System, Veterans Health Administration, and civilian health care facilities.

PARTICIPANTS

Active duty service members, veterans, and retirees seeking health care for LBP between January 2017 and December 2020, with no LBP diagnoses for at least 1 year prior (N=1,252,959).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Time to-outpatient PT evaluation within 13 weeks of LBP diagnosis.

RESULTS

Approximately 9.4% of included patients received an outpatient PT evaluation from a physical therapist within 13 weeks of diagnosis. In a piecewise exponential additive model, many covariates were time-varying, such that the probability of PT receipt varied throughout the 13-week period. Black, Latinx, and American Indian and Alaskan Native patients had lower probabilities of PT receipt than White patients from 1 to 3-6 weeks after index diagnosis. At 5 and 7 weeks, Black and Latinx patients, respectively, were more likely to receive PT than White patients, which continued until the end of the observation period. Patients assigned female relative to patients assigned male relative had a higher probability of initiating PT across the entire observation window, as did active duty service members, relative to retired service members and veterans.

CONCLUSIONS

Inequities in the timing and receipt of PT exist in the US Military Health System and Veterans Health Administration by race and ethnicity, assigned sex, and beneficiary group. Standardizing referral and practice patterns, improving accessibility of PT services, and encouraging health-seeking behavior may help alleviate the inequities in initiating PT.

Therapeutic Exercise is Effective in Reducing the Intensity of Nonspecific Low Back Pain in Children and Adolescents: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the different physiotherapy treatments and determine the most effective treatment to reduce the nonspecific low back pain (NSLBP) intensity in children and adolescents.

DATA SOURCES

Eight databases (Cochrane Library, MEDLINE, PEDro, Web of Science, LILACS, IBECS, PsycINFO, and SCOPUS), and 2 health-specialized journals (BMJ and Spine) were searched from inception to May 2023, with no language restriction.

STUDY SELECTION

Individuals aged 6-18 years with NSLBP were selected, and physical therapy treatments were considered. Studies were required to be controlled clinical trials with pretest and posttest evaluations, and to report pain intensity.

DATA EXTRACTION

Data extraction and risk of bias assessment were performed independently by 2 reviewers.

DATA SYNTHESIS

A meta-analysis of 11 controlled trials with 827 participants found that physiotherapy treatments effectively reduced NSLBP intensity on posttest measurement (d+=0.75; 95% confidence interval [CI], 0.30-1.20) and 6-month follow-up (d+=0.35; 95% CI, -0.72 to 1.40). Network meta-analysis showed both therapeutic exercise (d+=1.11; 95% CI, 0.48-1.74) and a combination of therapeutic exercise and manual therapy (d+=1.45; 95% CI, 0.40-2.49) were effective compared to no treatment. There were no significant differences between therapeutic exercise and the combination of therapeutic exercise and manual therapy.

CONCLUSIONS

Physical exercise has proven to be the most effective treatment for addressing the intensity of NSLBP in children and adolescents. While combining it with manual therapy may yield even better results, it is crucial to emphasize that physical exercise should serve as the cornerstone in the physiotherapeutic approach to managing NSLBP intensity in this age group.

The shifting global landscape of low Back pain attributable to high body mass index: Burden, growth, and inequalities

Background

Low back pain (LBP) is the leading global cause of years lived with disability (YLD), with high body mass index (BMI) recognized as a significant and modifiable risk factor. While prior research has linked high BMI to LBP, comprehensive global assessments of the burden attributable to high BMI are scarce.

Methods

We analyzed data from the Global Burden of Disease (GBD) study (1990-2021) to estimate global and regional YLDs of LBP attributable to high BMI, stratified by age, sex, and socio-demographic index (SDI). The Autoregressive Integrated Moving Average (ARIMA) model projected the future burden to 2050.

Results

From 1990 to 2021, global YLDs of LBP attributable to high BMI nearly doubled, reaching 8.4 million (95 % uncertainty interval: 0.8-17.4), with an age-standardized rate of 97.7 per 100,000. Burdens rose across all regions, with the steepest increases in middle- and lower-SDI areas. Women consistently experienced nearly double the burden compared to men. High-income North America had the largest YLD counts, while South Asia showed the fastest growth. YLDs peaked among individuals aged 40-70, with an emerging burden in the 20-40 age group. Projections suggest disproportionate increases in high- and high-middle-SDI regions by 2050.

Conclusion

The rising burden of LBP attributable to high BMI underscores the urgent need for targeted public health strategies. Integrating BMI management and musculoskeletal health initiatives into healthcare policies could mitigate LBP-related disability and enhance global population health outcomes.

A cross-sectional study on ChatGPT's alignment with clinical practice guidelines in musculoskeletal rehabilitation

BACKGROUND

AI models like ChatGPT have the potential to support musculoskeletal rehabilitation by providing clinical insights. However, their alignment with evidence-based guidelines needs evaluation before integration into physiotherapy practice.

OBJECTIVE

To evaluate the performance of ChatGPT (GPT-4 model) in generating responses to musculoskeletal rehabilitation queries by comparing its recommendations with evidence-based clinical practice guidelines (CPGs).

DESIGN

This study was designed as a cross-sectional observational study.

METHODS

Twenty questions covering disease information, assessment, and rehabilitation were developed by two experienced physiotherapists specializing in musculoskeletal disorders. The questions were distributed across three anatomical regions: upper extremity (7 questions), lower extremity (9 questions), and spine (4 questions). ChatGPT's responses were obtained and evaluated independently by two raters using a 5-point Likert scale assessing relevance, accuracy, clarity, completeness, and consistency. Weighted kappa values were calculated to assess inter-rater agreement and consistency within each category.

RESULTS

ChatGPT's responses received the highest average score for clarity (4.85), followed by accuracy (4.62), relevance (4.50), and completeness (4.20). Consistency received the lowest score (3.85). The highest agreement (weighted kappa = 0.90) was observed in the disease information category, whereas rehabilitation displayed relatively lower agreement (weighted kappa = 0.56). Variability in consistency and moderate weighted kappa values in relevance and clarity highlighted areas requiring improvement.

CONCLUSIONS

This study demonstrates ChatGPT's potential in providing guideline-aligned information in musculoskeletal rehabilitation. However, due to observed limitations in consistency, completeness, and the ability to replicate nuanced clinical reasoning, its use should remain supplementary rather than as a primary decision-making tool. While it performed better in disease information, as evidenced by higher inter-rater agreement and scores, its performance in the rehabilitation category was comparatively lower, highlighting challenges in addressing complex, nuanced therapeutic interventions. This variability in consistency and domain-specific reasoning underscores the need for further refinement to ensure reliability in complex clinical scenarios.

CLINICAL TRIAL NUMBER

Not applicable.

Effects of an additional multimodal intervention (MultiMove) during inpatient rehabilitation on clinical and functional outcomes in patients with chronic low back pain- a pilot trial

BACKGROUND

As a leading cause of disability, chronic low back pain (CLBP) is a musculoskeletal condition often associated with impaired physical and cognitive functions. Due to its multi-factorial facets, the application of multimodal interventions is recommended. MultiMove is a multimodal intervention designed for CLBP patients, which combines motor-cognitive and dancing exercises. This study aimed to assess the effects of an additional MultiMove intervention to a standard inpatient rehabilitation on clinical and functional outcomes in CLBP patients.

METHODS

For this prospective, two-arm, controlled pilot trial, 27 CLBP patients (17 females, 10 males) undergoing a 3-week inpatient rehabilitation, in a rehabilitation clinic in Germany, were recruited. The intervention group (IG, n = 15, 61.6 ± 1.8 years) received a daily MultiMove session in addition to the standard rehabilitation, while the control group (CG, n = 12, 63.8 ± 2.2 years) followed the standard rehabilitation. Physical (Timed Up and Go (TUG) [primary outcome], Five-Repetition Sit-to-Stand (FRSTS), and Six-Minute Walk Test (6MWT), trunk range of motion, single and dual task walking)), clinical (acute/chronic pain intensity, Oswestry Disability Index, EQ-5D-5 L), cognitive (Stroop Color Word Test, Trail Making Test), and psychosocial outcomes (Tampa Scale of Kinesiophobia, Beck Depression Inventory-II, Coping Strategies Questionnaire) were assessed during the first (pre-test) and last day (post-test) of the inpatient rehabilitation.

RESULTS

The statistical analyses revealed improvements in trunk range of motion (sagittal plane: p = 0.018, d = 1.00; transversal plane: p = 0.006, d = 1.18) and 6MWT performance (p = 0.003, d = 1.30) in the IG compared to the CG. Moreover, lower dual task costs for a gait variability measure (p = 0.034, d = 0.97) as well as reduced chronic pain intensity (p = 0.004, d = 1.33), kinesiophobia (p = 0.035, d = 1.15), and depression (p = 0.034, d = 1.08) were found in favour of the IG.

CONCLUSION

Data indicate that the multimodal intervention MultiMove improved clinical and functional outcomes in CLBP patients during inpatient rehabilitation. Therefore, conducting a randomized controlled trial with a large sample size is recommended to verify and extent these results.

TRIAL REGISTRATION

MultiMove project (German Clinical Trial Register, ID: DRKS00021696 / 10.07.2020, https://drks.de/drks_web/navigate.do?navigationId=trial.HTML26TRIAL_ID=DRKS00021696 ) and was carried out in the rehabilitation clinic Bad Salzelmen (Schönebeck, Germany).

Predicting Work Disability Related to Spinal Pain: A Systematic Review of the Most Clinically Relevant Tools

PURPOSE

Musculoskeletal disorders, especially spinal conditions, are leading causes of disability, contributing significantly to work absenteeism and socio-economic burden. Rehabilitation is essential for promoting sustainable return to work (RTW). However, clinicians need reliable tools with appropriate psychometric properties to determine patients' risk of persistent work disability and tailor interventions. This systematic review objectives were to (1) identify clinically useful questionnaires that enable clinicians to identify individuals with spinal pain (back or neck pain) at risk of work disability, and (2) document the psychometric properties of the identified questionnaires.

METHODS

A systematic search was conducted in three databases from inception to 01/10/2025, to retrieve relevant studies. Studies were included if they reported self-administered questionnaires with ≤ 15 items predicting RTW outcomes in spinal disorders. Tools were evaluated based on psychometric properties (calibration, discrimination), and pragmatic characteristics (number of items, readability).

RESULTS

Seventeen studies were retrieved including 16 unique questionnaires of which four demonstrated sufficient discrimination capability. From these, the Örebro musculoskeletal pain questionnaire 10-items (ÖMPQ- 10), STarT Back screening tool (SBST), and a single item from the ÖMPQ- 25 demonstrated acceptable to excellent discrimination for low back pain populations, but showed lower discrimination for mixed or neck pain populations.

CONCLUSION

The SBST, ÖMPQ- 10, and single items from the ÖMPQ- 25 performed best in predicting RTW outcomes for low back pain. No questionnaire had sufficient discriminatory capability for neck pain. These results should be interpreted with caution, as the overall risk of bias assessment remains unclear for the OMPQ- 10 and high for the SBST. Further research is necessary to develop or validate tools specific to neck pain and mixed populations.

Treatment preferences of patients with chronic low back pain in physical therapy clinics in Saudi Arabia: a cross-sectional study

Background

Low back pain (LBP) is a prevalent musculoskeletal disorder that significantly contributes to disability and health care burden. Clinical practice guidelines (CPGs) recommend non-pharmacological interventions, such as those delivered by physical therapists, to improve clinical outcomes. Incorporating patient preferences into treatment decisions is essential for promoting patient-centered care and enhancing adherence to CPGs. This study aimed to explore the physical therapy treatment preferences of patients with chronic LBP (CLBP) in Saudi Arabia and to evaluate their alignment with CPG recommendations.

Methods

This cross-sectional survey-based study was conducted across three healthcare centers in Saudi Arabia. Patient preferences were assessed using a validated questionnaire that listed available physical therapy treatments for CLBP. The participants were provided with a standardized explanation of evidence-based treatment options based on the updated CPGs for LBP before selecting their preferred treatments. Data analysis included descriptive statistics and chi-square tests to assess the alignment of preferences with CPG recommendations.

Results

A total of 138 participants were included, with 60.1% of the selected treatments aligning with CPG recommendations (p < 0.001). Sociodemographic factors, such as sex, prior physical therapy experience, and body mass index (BMI), influenced treatment preferences. Exercise was the most preferred treatment, aligning with CPGs, while passive modalities, such as interferential therapy, were also frequently chosen despite not being recommended.

Conclusion

This study highlights the importance of understanding patient preferences to improve adherence to CPGs and promote evidence-based care for CLBP. Educational interventions tailored to the cultural context can bridge the gap between patient preferences and evidence-based recommendations, empower patients, and enhance clinical outcomes.

Physician referrals of patients with neck and low back pain for physical therapy in outpatient clinics: a cross-sectional study

BACKGROUND

Patients commonly seek outpatient physical therapy services for musculoskeletal disorders. Understanding these patient groups in Israel provides valuable insights into the healthcare system. We aimed to investigate physician referral patterns for physical therapy across different age and sex groups, focusing on neck and low back pain. Additionally, we sought to explore the therapeutic interventions provided by physical therapists for these conditions.

METHODS

For this retrospective, cross-sectional study we utilized data from a national health maintenance organization covering > 4 million people at 100 physical therapy outpatient clinics. We measured the prevalence rates of physicians' referral patterns for neck and low back pain according to age and sex, as well as therapeutic interventions prescribed by physical therapists. We used Z-tests to assess the differences in prevalence rates between women and men within the same age group. Logistic regression analyses were used to evaluate the likelihood of patients of a specific age group being referred to physical therapy compared with the total sample. We analyzed prevalence rates of different treatment protocols used by physical therapists according to these referrals.

RESULTS

Overall, 1,593,592 physician referrals for physical therapy were made over 6 years for all musculoskeletal conditions. Of those, 32.4% were for spine disorders, with 21.2% for low back pain and 11.1% for neck pain, mostly chronic (80.6% and 72.7%, respectively). Women were more likely than men to be referred for both low back pain (odds ratio = 1.36, 95% confidence interval = 1.34-1.38, p < 0.001) and neck pain (1.40, 1.37-1.43, p < 0.001). All referral rates increased with age. The most common treatment provided by physical therapists for neck and low back pain was education and advice for an active lifestyle.

CONCLUSIONS

This study provides comprehensive data that highlight significant trends related to age, acuteness, and sex. Chronic low back and neck pain are the predominant reasons for physical therapy referrals, particularly among women and older adults. Physician referrals for neck and low back pain aligned with the epidemiology of such conditions in the Israeli population, underscoring the need for targeted rehabilitation strategies, early intervention programs, and effective healthcare service planning.

Back pain in the midwifery profession in northern Poland

Background

Neck pain (NP) and low back pain (LBP) are increasingly significant medical, social, and economic concerns. The midwifery profession, similar to other healthcare occupations, is particularly predisposed to these issues.

Methods

This study aimed to analyze the prevalence of back pain among midwives and evaluate the associated disability levels using the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI). The study group included 208 actively practicing midwives aged 23 to 67 years (mean ± SD: 48.1 ± 10.7 years). Participants completed an anonymous survey comprising a custom-designed questionnaire, the Polish language versions of the NDI and ODI, and the Visual Analog Scale (VAS) for pain intensity.

Results

The analysis revealed a statistically significant correlation between VAS pain intensity and both age (r = 0.2476) and work experience (r = 0.2758), indicating higher pain scores with increasing age and seniority. No significant association was found between BMI and VAS scores (r = 0.0011). Additionally, NDI and ODI scores correlated significantly with age (r = 0.1731; r = 0.3338), BMI (r = 0.1685; r = 0.2718), and work experience (r = 0.1987; r = 0.4074). Higher values for age, BMI, and seniority were associated with increased disability levels.

Conclusions

Neck and low back pain represent prevalent and impactful issues for midwives in Poland, contributing to mild to moderate disability, absenteeism, reliance on pain medication, and limited physical activity. Key contributing factors include age, professional experience, BMI, and low levels of physical activity.

Do clinical practice guidelines for low back pain include predatory journal or retracted publications? A meta-research study

BACKGROUND

Following clinical practice guidelines is widely recommended for treating many musculoskeletal diagnoses, including low back pain, but it is unknown if clinical practice guidelines for low back pain do.

OBJECTIVE

Assess whether clinical practice guidelines for low back pain reference publications from predatory journals or include retracted publications.

DESIGN

Meta-research.

METHODS

Clinical practice guidelines focusing on the management of adults with low back pain published between January 2010-June 2024 were included. All referenced publications in each guideline were evaluated for predatory categorization using a systematic process that included assessing publisher/journal websites, the Directory of Open Access Journals, Beall's List and major literature databases. The Retraction Watch Database was used to assess retraction status.

RESULTS

Nineteen clinical practice guidelines with 1617 unique publications met inclusion criteria. The majority of publications (1598/1617; 98.8 %) were categorized as 'non-predatory.' Fourteen publications (0.9 %) were categorized as 'predatory,' two (0.1 %) 'presumed predatory,' and three (0.2 %) were retracted. Four guidelines cited 'predatory' and/or 'presumed predatory' publications, and four guidelines cited the retracted publications.

CONCLUSION

Only 1.2 % of the cited publications included in clinical practice guidelines for the management of low back pain were deemed predatory or retracted, implying that guideline recommendations are unlikely to be influenced by their inclusion. There are currently no standard criteria for how to manage the inclusion of these publications in guidelines or systematic reviews. Future research should investigate the development of a valid and reliable checklist that allows authors to assess for and manage the presence of predatory or retracted publications.

The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews

INTRODUCTION

Treatment mechanisms are the underlying process or pathway through which a treatment influences the body. This includes molecular, cellular and physiological processes or pathways contributing to treatment effect. Manual therapy (MT) evokes complex mechanistic responses across body systems, interacting with the individual patient and context to promote a treatment response. Challenges arise as mechanistic studies are spread across multiple professions, settings and populations. The purpose of this review is to summarize treatment mechanisms that have been reported to occur with MT application.

METHODS

Four electronic databases were searched (Medline, CINAHL, Cochrane Library, and PEDro) for reviews investigating mechanistic responses which occur during/post application of MT. This review was registered a priori with PROSPERO (CRD42023444839). Methodological quality (AMSTAR-2) and risk of bias (ROBIS) were assessed for systematic and scoping reviews. Data were synthesized by mechanistic domain.

RESULTS

Sixty-two reviews were included. Systematic reviews (n = 35), narrative reviews (n = 24), and scoping reviews (n = 4) of asymptomatic (n = 37), symptomatic (n = 43), non-specified human subjects (n = 7) and animals (n = 7) were included. Reviews of moderate quality supported neurovascular, neurological, and neurotransmitter/neuropeptide changes. Reviews of low quality supported neuroimmunce, neuromuscular, and neuroendocrine changes. Reviews of critically low quality support biomechanical changes.

CONCLUSIONS

Findings support critically low to moderate quality evidence of complex multisystem mechanistic responses occurring with the application of MT. Results support peripheral, segmental spinal, and supraspinal mechanisms occurring with the application of MT, which can be measured directly or indirectly. The clinical value of these findings has not been well established. While MT has proven to be an effective intervention to treat conditions such as pain, the current body of literature leaves uncertainty as to 'why' MT interventions work, and future research should look to better define which mechanisms (or combinations of mechanisms) are mediators of clinical response.

Physical activity and factors associated with the costs of low back pain among adults after 18 months of follow-up: a cohort study

BACKGROUND

Chronic low back pain (CLBP) is a substantial health problem that causes considerable economic losses. Several studies have demonstrated the protective effect of habitual physical activity; however, little data are available regarding its impact on the costs associated with CLBP.

OBJECTIVES

The primary aim of this study was to analyze the costs of CLBP in the Brazilian Health System and associated factors among adults.

DESIGN AND SETTING

An 18-month cohort study was conducted in two basic health units in Presidente Prudente (SP), Brazil.

METHODS

A total of 198 patients were interviewed and evaluated four times: at baseline, with retrospective data covering the previous 12 months, and at six, 12, and 18 months. The Nordic and Baecke questionnaires were used to classify CLBP, and the Baecke questionnaire was used for physical activity assessment. The costs were calculated by reviewing the demand for services from medical records. Body mass index (kg/m2) was determined using body mass and height values collected during the interviews. The questionnaire included confounding variables, such as sex, age, ethnicity, and socioeconomic status.

RESULTS

A high prevalence of CLBP was observed, which was associated with female sex and younger age. CLBP resulted in high costs for medical consultations (without: US$ 34.25 ± 23.21; with: US$ 39.62 ± 27.25; P = 0.049), while cycling was negatively associated with costs (rho = -0.289; P = 0.049).

CONCLUSION

Lower back pain was associated with higher costs of medical consultations, while cycling was associated with reduced costs.

The Arabic Oswestry Disability Index as a Unidimensional Measure: Confirmatory Factor Analysis

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate the structural validity of the Arabic version of the Oswestry disability index (ODI) in patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The Arabic ODI is currently used in clinical and research settings to assess disability, but questions remain regarding its structural validity.

MATERIALS AND METHODS

Adult patients with LBP were recruited from physical therapy departments of two hospitals in Saudi Arabia. Participants completed the Arabic ODI and the numeric pain rating scale. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to examine the factor structure of the ODI. Maximum likelihood extraction and parallel analysis were used in the EFA, and the goodness-of-fit indices [χ 2 statistics, Tucker-Lewis index (TLI), comparative-fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean residual (SRMR)] were assessed in the CFA to confirm the factor structure.

RESULTS

A total of 113 patients (47.8% male, 52.2% female) participated. The EFA identified a unidimensional structure for the Arabic ODI, with one factor explaining 45.8% of the total variance. All items had significant factor loadings, with loadings ranging from 0.48 (sleeping) to 0.84 (sex life and social life). The CFA confirmed this unidimensional structure, yielding good fit indices [χ 2 =49.53, P <0.04; TLI=0.96; CFI=0.97; RMSEA=0.06 (90% CI=0.07-0.10), SRMR=0.04]. All ODI items exhibited significant positive loadings consistent with the expected correlation between the single latent variable (LBP-related disability) and the ODI items. A high error covariance was observed between items related to walking and standing.

CONCLUSION

The Arabic Oswestry disability index demonstrates sufficient structural validity as a unidimensional measure of disability in Arabic-speaking patients with low back pain. These findings support the continued use of the Oswestry disability index for disability assessment in clinical and research settings and support the validity of using one total score representing the single underlying latent construct.

LEVEL OF EVIDENCE

Level III.

The effectiveness of instrument-assisted soft tissue mobilization on pain and function in patients with musculoskeletal disorders: a systematic review and meta-analysis

BACKGROUND

Instrument-assisted soft tissue mobilization (IASTM) is popular in the treatment of musculoskeletal disorders. However, the current literature has produced varying results. The purpose of this study was to collect the most recent studies to evaluate the effectiveness of IASTM on pain and function in patients with musculoskeletal disorders.

METHODS

The researchers searched the PubMed, Embase, Web of Science, and Cochrane Library databases from inception to February 25, 2025, to identify randomized controlled trials comparing treatment groups receiving IASTM combined with other treatments to those receiving other treatments among participants with musculoskeletal disorders. The outcomes were pain intensity, pain pressure threshold and function. The Cochran Q and I² indices were used to estimate heterogeneity. The data were analyzed as the standardized mean difference (SMD). The Cochrane Risk of Bias tool was used to assess the risk of bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the quality of evidence. Trial sequential analysis and sensitivity analyses were also performed.

RESULTS

Eleven trials (involving 427 participants) were included in the quantitative analysis. Six trials had a high risk of bias; three, unclear; and two, low. There was moderate-certainty evidence indicating that IASTM was effective in reducing patient-reported pain (n = 11) (n = 427, SMD = 0.60, 95% CI: 0.41 to 0.80, p < 0.01), and there was low-certainty evidence indicating that IASTM was effective in improving patient-reported function (n = 8) (n = 333, SMD = 0.40, 95% CI: 0.03 to 0.77, p < 0.05). Only one data point was extracted for the pain pressure threshold, and a meta-analysis was not performed. Trial sequential analysis revealed that the cumulative z score crossed the monitoring boundary for superiority for patient-reported pain in patients with nonspecific chronic neck pain and cervicogenic headache at the 4-week IASTM.

CONCLUSIONS

IASTM can reduce patient-reported pain (with moderate certainty) and improve patient-reported function (with low certainty) in patients with musculoskeletal disorders. Future clinical studies do not need to explore the short-term effects of IASTM on patient-reported pain in patients with nonspecific chronic neck pain and cervicogenic headache.

TRIAL REGISTRATION

The PROSPERO registration ID is CRD42024534643 (April 10, 2024).

The association between education, practice, post-professional training and physical therapists' attitudes and beliefs regarding low back pain management: A cross sectional survey study

INTRODUCTION

Several recent initiatives have aimed to align physical therapists' (PTs) understanding and management of low back pain (LBP) with the biopsychosocial model of health and illness.

PURPOSE

The purpose of this study was to determine whether entry-level education, practice setting, experience, or post-professional training is associated with attitudes and beliefs of United States (US) PTs about LBP management, despite these initiatives.

METHODS

A cross-sectional online survey was distributed to a sample of US PTs that included the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). Linear regression was used to quantify the association between education, experience, post-professional training, and practice setting with PTs attitudes and beliefs.

RESULTS

Of 412 respondents, those with a Bachelor's/Master's scored significantly higher on the PABS-Bio (β = 2.5, 95 % CI = 0.76-4.3, p = 0.005) and HC-PAIRS (β = 2.7, 95 % CI = 0.7-4.6, p = 0.006) and lower on the PABS-Psy (β = 1.7, 95 % CI = -2.7-0.7, p < 0.001) compared to those with a DPT/tDPT. Those who did not undertake post-professional training scored higher on the PABS-Bio (β = 3.7, 95 % CI = 1.4-6.1, p = 0.002) and HC-PAIRS (β = 3.9, 95 % CI = 1.2-6.6, p = 0.005). Therapists licensed 20+ years and working in settings besides outpatient had stronger biomedical beliefs.

CONCLUSION

Highest degree, post-professional training, years licensed, and practice setting were all significantly associated with attitudes and beliefs of practicing PTs in the US regarding LBP management. This study highlights the need for further investigation into education for improving PTs' attitudes and beliefs around LBP amidst diverse practice settings and experience.

Evaluation of lumbar segmental motion using ultrasound imaging following common joint mobilization techniques

OBJECTIVES

Spinal mobility is clinically important in managing mechanical low back pain. Manual methods are commonly used for diagnosis and treatment in orthopedic practice. This study quantified changes in sagittal plane lumbar segmental motion using ultrasound imaging (USI) following common joint mobilization techniques in asymptomatic individuals. Additionally, tibial H-reflexes and sagittal plane trunk motion in standing were evaluated for association with lumbar segmental motion.Participants aged ≤ 30 or ≥ 50 years were recruited from among students, faculty, and affiliates of the Department of Physical Therapy at Winston-Salem State University and randomized to receive L4 central posterior-to-anterior (CPA) mobilization or left lumbar rotation mobilization interventions. Joint laxity was assessed using the Beighton score, and standing sagittal plane trunk motion was measured using the fingertip-to-floor method. Lumbar segmental motion was evaluated using USI in neutral, extension, and flexion positions at baseline, immediately following joint mobilization, and following 5 minutes of prone resting. Tibial H-reflexes were measured at baseline, immediately following joint mobilization, and in real-time during CPA mobilization. The primary outcome was lumbar segmental motion analyzed by position, mobilization group, sex, age category, and Beighton risk.

RESULTS

Repeated measures ANOVA revealed significant increases in L4/5 flexion (p = .01, ƞ2=.21) and combined flexion and extension (p = .03, ƞ2=.15). These changes persisted following 5 minutes of prone resting, regardless of mobilization technique. Significant interactions between segmental motion, sex, and/or Beighton risk were observed.

DISCUSSION/CONCLUSION

Significant increases were observed in L4/5 flexion immediately following joint mobilization regardless of mobilization group, with significant statistical interactions observed between segmental motion, sex, and/or Beighton risk. This is the first investigation to demonstrate the value of USI for quantifying lumbar segmental motion following joint mobilization. Quantifying lumbar segmental motion helps clarify the underlying mechanisms of manual therapy. Future studies should include patients with low back pain.

Effectiveness of Electromagnetic Field Therapy in Mechanical Low Back Pain: A Randomized Controlled Trial

Background

Between half and three quarters of the working-age population in today's industrialized globe suffers from lower back pain. The presence of a myofascial trigger point-a hyperirritable painful area comprised of a small number of muscle fibers-identifies mechanical back pain sufferers as suffering from myofascial pain syndrome, a chronic pain disorder. This research objectives to determine whether mechanical back pain patients' pain severity and functional disabilities are influenced by electromagnetic field therapy.

Methods and Subjects

Two groups of thirty patients were randomly assigned. The 15 participants in group A underwent conventional physical therapy (including ultrasound, stretches, and strength training for the back muscles), while the 15 participants in group B received a combination of conventional physical therapy and electromagnetic field therapy. Pre- and post-treatment assessments of pain intensity, functional impairment, and lumbar range of motion (including extension, flexion, and right and left side bending) were examined. The variables of interest that were examined at various testing groups and measuring periods were compared using a 2×2 mixed design MANOVA.

Results

After treatment, there was a significant difference in all dependent variables between the two groups in terms of between-subject effects (p <0.05). Group B benefited from a significant decrease in pain, right and left side bending, and function disability, as well as an increase in flexion and extension.

Conclusion

Patients suffering from mechanical back pain can find relief from their discomfort and functional impairment through the use of electromagnetic field therapy, according to the current study's conclusions.

A Critical Review of Trunk and Hip Exercise Prescription: Applying Evidence for a Modern Approach

Exercise targeting the trunk and hip (core) musculature is common practice in rehabilitation and performance training. Historical underpinnings of core exercise focus on providing stability to the spine, thus improving the function of the spine and extremities, while instability has been postulated to result in pathology and impaired performance. Mechanistic studies on the topic are often conflicting and indeterminate, suggesting the theoretical underpinnings of targeted core exercise may be over assumed in common practice. The best modes of intervention also remain undefined, with combined methods having potential to optimize outcomes. This includes moving beyond isolated exercise camps and being inclusive of both targeted exercise and progressive multi-joint movements. The purpose of this clinical commentary is to describe the historical mechanisms of the stability-instability continuum and the role of exercise intervention. A spectrum of ideologies related to core exercise are examined, while appreciating positive outcomes of exercise interventions across healthy and pathological populations. Finally, exercise summaries were compiled to improve critical reasoning within current practice and inspire future investigations.

Level of Evidence

5.

Gaps in Evidence-Based Recommendations for Low Back Pain: Analysis of the Accuracy of the Care Pathway in Primary Care

BACKGROUND

Primary health care is the gateway to low back pain (LBP) management. Effective management of LBP can reduce disability and socioeconomic burden. Standardised, accurate, and evidence-based information for assertive decision-making in care pathways for LBP has the potential to improve health service efficiency.

OBJECTIVE

To describe and analyse the accuracy of the information on the care pathway for the management of LBP in primary care provided by the Ministry of Health from Brazil.

METHODS

Descriptive study of the accuracy of information on the care pathway for LBP in primary care based on an official protocol of the Ministry of Health from Brazil. Information on non-pharmacological and pharmacological treatment, as well as health education, was extracted from the treatment protocol. The information was then compared with recent international guidelines for accuracy analysis. Each management recommendation was analysed by two independent researchers and classified as accurate, partially accurate, inaccurate or not mentioned according to the clarity and precision of the information.

RESULTS

The analysis revealed that 43% of the management recommendations were accurate, 30% were partially accurate, and 26% of the recommendations presented in the investigated guidelines were not mentioned in the Ministry of Health's care pathway. Pharmacological recommendations showed 50% accuracy, non-pharmacological recommendations 60%, and health education recommendations 14%. Additionally, the care pathway appears to be outdated in recommending educational guidance that is not aligned with current clinical guidelines.

CONCLUSION

The results indicate that, although there some aspects of the information provided by the Brazilian official management protocol align with international clinical guidelines, there are substantial gaps, especially in the areas of health education and non-pharmacological interventions. This study may contribute to making more accurate information available on LBP, bringing primary care professionals in Brazil closer to evidence-based recommendations.

Addressing pain in people living with cystic fibrosis: Cystic fibrosis foundation evidence-informed guidelines

Even as many outcomes for people living with cystic fibrosis (PLwCF) improve, individuals still experience extensive symptom burdens. From birth, many PLwCF experience both pain as a symptom of their CF disease and procedural pain, posing detriments to health, functioning, and quality of life. Despite its prevalence and impact, there is no CF-specific guidance for the assessment and management of pain. Similarly, no guidance exists regarding communication with PLwCF about their pain experiences or its impact on their lives. Therefore, the Cystic Fibrosis Foundation (CFF) assembled an expert panel of clinicians, researchers, PLwCF, and caregivers to develop consensus recommendations for pain management in CF. We utilized literature review and expert opinion to develop 13 recommendations addressing pain assessment, management, and communication. Recommendations are centered on guiding principles of utilizing a multimodal approach to pain management, offering age and developmentally appropriate assessment and interventions, concurrently treating underlying conditions causing, contributing to, and/or exacerbated by pain, considering societal stigma of the pain experience, particularly for minoritized and marginalized people, and sensitivity to issues of access and cost. These recommendations are intended to guide clinicians in managing pain and improving quality of life for PLwCF with pain at all stages of illness and development.

Gamified delivery of at-home rehabilitation for individuals with nonspecific low back pain: a randomized controlled trial

PURPOSE

To measure the change in pain and disability during and after a 6-week gamified delivery of home exercise compared to a take-home packet.

MATERIALS AND METHODS

A 6-week at-home exercise protocol included participants randomly allocated to a gamified delivery group or packet group. The exercise protocol included the plank, side plank, foot elevated side plank, dead bug, and bird dog completed until discontinuation. The gamified delivery group received on-demand exercise videos and weekly exercise duration leaderboards. The packet group received a take-home packet.

RESULTS

Forty participants were randomized into a packet group and leaderboard group, and 30 participants completed the study. Disability was significantly lower at 6-weeks (11.29 ± 9.81%) compared to baseline (15.93 ± 11.65%) in the packet group (χ2(2) =10.89, Z= -3.163, p=.002, r=.708). Percent disability was significantly lower at 6-weeks (8.00 ± 5.91%) compared to baseline (13.01 ± 7.17%) in the gamified delivery group (χ2(2) =13.235, Z= -3.399, p= <.001, r= -0.760). Worst pain was higher at baseline (7.05 ± 1.61%) than at 6-weeks (5.75 ± 1.68%) in the packet group (χ2(2) =8.067, Z = 2.760, p=.006, r= -0.617). Worst pain was higher at baseline (6.90 ± 1.33%) than at 6-weeks (5.24 ± 2.38%) in the gamified delivery group (χ2(2) =6.250, Z= -2.810, p=.005, r= -0.628). No significant difference in the change of disability from baseline to 6 weeks was found between groups (p=.483).

CONCLUSIONS

Core exercises completed until failure may improve disability and pain at 6-weeks and positively influence perceived patient improvement.Registry: Clinicaltrials.gov; Registration number: NCT05573932.

Bibliometric analysis of research on manual therapy for low back pain from 2013 to 2023

BACKGROUND

Low back pain (LBP) is one of the most common symptoms prompting patients to seek treatment. Manual therapy is widely used to treat LBP. Nevertheless, there is a scarcity of bibliometric analyses examining the worldwide utilization of manual therapy for the treatment of LBP.

METHODS

This research used the Online Bibliometric overview Platform website (https://bibliometric.com), CiteSpace (6.2.R4), and VOSviewer (1.6.19) to provide a comprehensive analysis of the current status and prospective developments in the field. The Web of Science Core Collection (WOSCC) database was searched for publications from August 1, 2013, to August 1, 2023 on manual therapy of low back pain.

RESULTS

Among the identified articles, 488 fit the criteria. The number of papers on manual therapy for LBP has progressively risen over in the past 10 years, whereas the average number of citations of these papers has decreased. The leading countries producing publications on this discipline were the USA, Canada, and China. There were 345 authors of the studies, with Christine M. Goertz having the most publications. The University of Southern Denmark was the institution that contributed the most to the field. The Journal of Manipulative and Physiological Therapeutics published many of the research papers in this field. Keyword analysis showed that the relationship between low back pain, spinal manipulation, and management has been present throughout the development of this research area.

CONCLUSIONS

Spinal manipulation, management, randomized controlled trials, Physical therapy, care and disability are the current research hotspots in the treatment of LBP with manual therapy. In addition, research on complementary medicine and clinical practice guidelines may become an important trend in the future.

Sex-specific asymmetry in lumbar paraspinal muscles among chronic low back pain patients: correlation with pain duration and intensity

Chronic low back pain (cLBP) is a multifactorial condition, including paraspinal muscle asymmetry. Understanding the relationship between muscle asymmetry and cLBP and how this varies by sex is crucial for targeted interventions. From January 2022 to December 2023, 250 participants were enrolled: 117 without back pain (no-BP) (61 females, 56 males) and 133 with cLBP (69 females, 64 males). MRI assessed the cross-sectional area (CSA), functional CSA (FCSA), and fat infiltration (FI) of the paraspinal muscles, including the psoas major (PM), quadratus lumborum (QL), erector spinae (ES), and multifidus (MF), at all lumbar levels. Asymmetry indices were calculated for CSA (CAI), FCSA (FCAI), and FI (FIAI). Data were analyzed using multiple linear and logistic regression. Muscle asymmetries were observed in both sexes and groups, with significant differences in the CSA and FCSA of the QL in males and notable FI asymmetries in the cLBP group. In women with cLBP, higher ES CAI and FCAI at L5/S1 (p < 0.05) and lower PM FCAI at L4/5 (OR 0.869, 95% CI 1.008-1.150, p = 0.03) were observed. FIAI was significantly higher in cLBP for ES at L2/3 and PM, MF, and ES at L4/5 (p < 0.05). Men with cLBP had lower PM CAI and FCAI at L1/2 and L4/5 (p < 0.05), with varying FIAI levels. FIAI correlated with cLBP duration and intensity in both sexes (p < 0.05). Paraspinal muscle asymmetry, particularly in fat infiltration, is associated with cLBP and varies by sex. These findings support sex-specific approaches to managing cLBP.

Exploring the Effect of an 8-Week AI-Composed Exercise Program on Pain Intensity and Well-Being in Patients With Spinal Pain: Retrospective Cohort Analysis

Background

Spinal pain, one of the most common musculoskeletal disorders (MSDs), significantly impacts the quality of life due to chronic pain and disability. Physical activity has shown promise in managing spinal pain, although optimizing adherence to exercise remains a challenge. The digital development of artificial intelligence (AI)-driven applications offers a possibility for guiding and supporting patients with MSDs in their daily lives.

Objective

The trial aimed to investigate the effect of an 8-week AI-composed exercise program on pain intensity and well-being in patients with spinal pain. It also examined the relationship between exercise frequency, pain intensity, and well-being. In addition, app usage frequency was examined as a proxy for app engagement.

Methods

Data from users who met the inclusion criteria were collected retrospectively from the medicalmotion app between January 1, 2020, and June 30, 2023. The intervention involved the use of the medicalmotion app, which provides 3-5 personalized exercises for each session based on individual user data. The primary outcomes assessed pain intensity and well-being using the numeric rating scale (NRS) and the Likert scale. Data were collected at baseline (t0), 4 weeks (t1), and 8 weeks (t2). The correlation between exercise frequency, pain intensity, and well-being was analyzed as a secondary outcome. In addition, average session length and frequency were measured to determine app engagement. Statistical analysis included ANOVA and Spearman correlation analysis.

Results

The study included 379 participants with a mean age of 50.96 (SD 12.22) years. At t2, there was a significant reduction of 1.78 points on the NRS (P<.001). The score on the Likert scale for well-being improved by 3.11 points after 8 weeks. Pain intensity showed a negative correlation with the number of daily exercises performed at t1 and t2. Well-being had a small negative correlation with the average number of exercises performed per day. The average number of exercises performed per day was 3.58. The average session length was approximately 10 minutes, and the average interaction with the app was 49.2% (n=27.6 days) of the 56 available days.

Conclusions

Overall, the study demonstrates that an app-based intervention program can substantially reduce pain intensity and increase well-being in patients with spinal pain. This retrospective study showed that an app that digitizes multidisciplinary rehabilitation for the self-management of spinal pain significantly reduced user-reported pain intensity in a preselected population of app users.

Insights into how manual therapists incorporate the biopsychosocial-enactive model in the care of individuals with CLBP: a qualitative study

BACKGROUND

Chronic low back pain (CLBP) presents a significant challenge for manual therapists. Recent advancements in pain research have highlighted the limitations of the traditional biomedical and biopsychosocial models, prompting the exploration of alternatives. The biopsychosocial-enactive (BPS-E) model has emerged as a promising alternative. This study aims to explore the application of the BPS-E model by manual therapists in managing CLBP and to initiate a meaningful dialogue about its use.

METHODS

This study adhered to the Standards for Reporting Qualitative Research. Guided by constructivist grounded theory, we conducted semi-structured interviews with ten manual therapists who are experts in the BPS-E model. Data collection, conceptualization, and analysis were systematically carried out to identify key themes and insights.

RESULTS

The core theme identified was "The person-centred approach," with three subthemes: "Opportunities in implementing the model", "Utilizing and Integrating Diverse Skills for Holistic Care", and "Challenges in implementing the model".

CONCLUSION

This study provides insights into how manual therapists incorporate the BPS-E model in their practice, demonstrating its advantages over the traditional biopsychosocial model. The findings highlight the need for further research and training to effectively implement the BPS-E model in clinical settings. This research begins an essential discussion on the potential of the BPS-E model to enhance care for CLBP patients.

Number of physiotherapy sessions in work-related absenteeism due to musculoskeletal disorders, by gender, age and occupation. A retrospective cohort study

BACKGROUND

The number of physiotherapy sessions needed to treat musculoskeletal conditions varies in the literature; age and gender may partly explain the discordant reports. However, no research has analysed whether occupation may influence this outcome in the working population.

OBJECTIVES

To assess the number of physiotherapy sessions performed for low back pain (LBP), cervicalgia (CG), and whiplash syndrome (WS) in workers on sickness absence, according to gender, age, and occupation.

METHODS

In this retrospective cohort study, the outcome variable was the number of physiotherapy sessions needed to recover from LBP, CG, and WS. Explanatory variables were sex, age, occupation, year when physiotherapy ended, and treatment centre. The adjusted median differences in the number of sessions (MDa) were calculated.

RESULTS

Older workers (55-65 years) needed a median of 2.6 additional sessions for LBP, 3.0 more sessions for CG, and 3.6 for WS. Men underwent fewer sessions than women (LBP and CG: MDa -0.9 sessions; WS: MDa -1.7 sessions). Compared to crafts and related trades workers, plant and machine operators and assemblers required more sessions to recover from LBP (MDa 0.7), as did service and sales workers (MDa 0.7). In CG and WS, differences were observed for technicians and associate professionals (MDa 1.3 and MDa 1.7, respectively), and for professionals (MDa 2.4 and MDa 1.6). Clerical support workers also needed significantly more sessions for CG.

CONCLUSIONS

The number of sessions required to recover from LBP, CG, and WS in workers on work-related sickness absence is different according to gender, age, and occupation.

Multimodal abnormalities of brain function in chronic low back pain: a systematic review and meta-analysis of neuroimaging studies

Objectives

Neuroimaging investigations into chronic low back pain (CLBP) have detected functional abnormalities across a spectrum of brain regions, yet the findings have often been inconsistent. In this meta-analysis, we integrated the existing data, delineating a pattern of coherent results from the encompassed studies.

Methods

A systematic search of neuroimaging studies investigating the brain activity differences between CLBP and Healthy controls (HCs) was conducted in seven databases up to December 22, 2024. An anisotropic effect-size signed differential mapping (AES-SDM)-based meta-analysis was carried out to report the results and perform a multimodal analysis.

Results

A total of 20 publications reporting on 24 experiments in this meta-analysis. The ReHo meta-analysis showed abnormal spontaneous activity of left inferior temporal gyrus (ITG), left superior frontal gyrus (SFG), right middle frontal gyrus (MFG), right precuneus, right fusiform gyrus and bilateral postcentral gyrus (PoCG) in CLBP patients. The ALFF meta-analysis demonstrated functional alterations in the right rolandic operculum (extending to the right insula and right IFG), left ITG, left middle occipital gyrus (MOG), left paracentral lobule, left PoCG and bilateral cuneus cortex in CLBP patients. The results of the functional group meta-analysis revealed that patients with CLBP displayed new decreased functional activity in the right thalamus, right precentral gyrus (PreCG) and right lingual gyrus.

Conclusion

Patients with CLBP exhibit extensive multimodal functional neuroimaging abnormalities, involving brain regions related to pain perception, emotional processing, cognitive functions, and both the visual and motor cortices. These meta-analysis findings might provide a valuable reference for the identification of potential therapeutic targets for CLBP in the brain.

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

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

Sensory profiles and their role in the persistence of central sensitization symptoms in low back pain. A prospective cohort study

INTRODUCTION

Acute lower back pain can lead to neuroplastic changes in the central nervous system, and symptoms of central sensitization after 12 weeks. While sensory sensitivity has been shown to predict symptoms of central sensitization, trait sensory profiles may be prognostic in the persistence of central sensitization symptoms in low back pain over time.

OBJECTIVE

To examine sensory profiles as prognostic symptoms of central sensitization in people with acute low back pain.

METHODS

A longitudinal type 2 prognostic factor research study was performed according to the PROGRESS framework. Baseline and 12-week follow-up measures were taken using the Adolescent/Adult Sensory Profile and the Central Sensitization Inventory measures. Study participants were consecutively included from primary care physiotherapy practices. Univariable, and multivariable regression analyses were performed to adjust sensory profiles based on previous history of low back pain, baseline Central Sensitization Inventory scores, level of pain, disability, age, and duration of low back pain.

RESULTS

After adjustment, the sensory profiles of Low Registration B = 0.44, 95%CI (0.18, 0.70), Sensation Seeking B = 0.38, 95%CI (0.19, 0.57), Sensory Sensitive B = 0.49, 95%CI (0.25, 0.74), Sensation Avoiding B = 0.40, 95% CI (0.15, 0.65) was significantly associated with the persistence of central sensitization symptoms (N = 103).

CONCLUSION

Sensory profiles may predict symptoms of central sensitization after 12 weeks in people with acute low back pain.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Hip joint kinematic assessment in chronic non-specific low back pain patients. A Delphi study

BACKGROUND

Chronic nonspecific low back pain (CNSLBP) has been associated with movement impairment (MI) of the hip joint. However, evidence supporting this is inconsistent. Agreement from experts may provide rationale and recommendations for the assessment of the hip joint in the management of CNSLBP patients.

OBJECTIVE

Gain expert consensus on whether hip MIs are related to CNSLBP, whether they should be assessed and which movement types and directions they recommend.

METHODS

Through a three-round e-Delphi process, international experts in the field rated levels of agreement for generated themes pertaining to assessing proposed hip joint MI in individuals with CNSLBP and underlying rationales. Consensus was defined a priori as ≥75% ratings on Likert scales with an IQR≤ 1.

RESULTS

International expert panel consisted of a mix of researchers and clinicians with the majority involved in both. Response for round I was 27, round 2 was 21 and round III was 26 individuals. Consensus was achieved for the association of active and passive hip joint MI in CNSLBP and their assessment. 100% agreement was achieved for the rationale regarding compensatory movement of the lumbar spine, and the assessment of passive hip movements, in particular extension. Consensus was also achieved for assessing hip passive flexion, extension, rotations, and abduction, active flexion, extension, and abduction. No agreement was attained regarding passive accessory movement.

CONCLUSION

The assessment of active and passive hip joint MI is regarded by experts as appropriate and informative in the management of and research pertaining to CNSLBP.

Sex-Specific Sensory Profiles Discriminate Between Sensitization at Twelve Weeks in Patients with Acute Low Back Pain: A Retrospective Study

Background/objective: Low back pain (LBP) is the leading cause of disability worldwide, resulting in enormous socio-economic and personal consequences. Sensory profiles during the acute back pain stage will predict central sensitization symptoms in the chronic pain stage, as central sensitization is the main mechanism behind nociplastic pain and pain chronicity. Therefore, our objective was to establish overall and sex-specific sensory profile cut-off points that distinguish symptoms of central sensitization at 12 weeks, using a retrospective prognostic cohort study design. Methods: Two hundred and seventeen patients with acute LBP (<6 weeks) were assessed using Receiver Operator Characteristic analyses. Measurements were taken at baseline using the Adolescent/Adult Sensory Profile and follow-up by the Central Sensitization Inventory at 12 weeks, based on the established Central Sensitization Inventory cut-off points for the overall population at ≥30 and ≥40, female patients at ≥33, and male patients at ≥25. Results: In female patients, a Sensory Sensitive cut-off point of ≥30.5 significantly distinguished central sensitization symptoms at 12 weeks, resulting in the following values: Area Under the Curve = 0.81 (95% CI = 0.73; 0.89), sensitivity = 0.89, specificity = 0.63, prevalence = 0.36, positive predictive value = 0.56, negative predictive value = 0.80, and Youden's index = 0.52. Conclusions: The Sensory Sensitive profile distinguishes female patients with acute LBP with and without central sensitization symptoms at 12 weeks. This cut-off point may be useful in identifying individual sensory preferences and addressing maladaptive behavioral responses to sensory stimulation in clinical practice to prevent chronicity.

Adherence to neck and low back pain clinical practice guidelines based on clinical specialization: a survey of physical therapists

OBJECTIVE

To investigate physical therapist adherence to the Academy of Orthopaedic Physical Therapy's (AOPT) clinical practice guidelines (CPGs) for the management of neck and low back pain (LBP) and to compare adherence among varying clinical specializations.

DESIGN

Electronic cross-sectional survey.

METHODS

The survey was sent to 17,348 AOPT members and 7,000 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) members. Participants selected the best diagnosis and intervention(s) for six case vignettes based on the current AOPT CPGs for neck and LBP. Diagnostic and intervention adherence rates were reported as total percentages and delineated by the highest level of clinical specialization - fellowship training (PTFs), orthopedic residency training (PTRs), Board Certified Clinical Specialist in Orthopaedic Physical Therapy (PTSs), orthopedic background without clinical specialization (PTOs). Binary logistic regression analyses were performed to determine the effects of clinical specialization (PTFs, PTRs, or PTSs) compared to PTOs on the likelihood of guideline adherence for all six cases.

RESULTS

Of the 159 participants who responded to the survey, 152 were eligible and 145 completed demographic data. Participant responses declined as the survey progressed from 125 completing case one to 106 completing case six. The odds ratio from binary logistic regression analyses were not significant for any specialization in all six cases (OR = 0.16; 95% CI: 0.02, 1.11; p = 0.064).

CONCLUSIONS

The results of this manuscript demonstrated variable adherence rates across subgroups of patients with neck and LBP with no significant association between clinical specialization and adherence. Adherence to CPGs is dependent on the clinical presentation of various patient cohorts.

Healthy Lifestyle Care vs Guideline-Based Care for Low Back Pain: A Randomized Clinical Trial

Importance

An unhealthy lifestyle is believed to increase the development and persistence of low back pain, but there is uncertainty about whether integrating support for lifestyle risks in low back pain management improves patients' outcomes.

Objective

To assess the effectiveness of the Healthy Lifestyle Program (HeLP) compared with guideline-based care for low back pain disability.

Design, Setting, and Participants

This superiority, assessor-blinded randomized clinical trial was conducted in Australia from September 8, 2017, to December 30, 2020, among 346 participants who had activity-limiting chronic low back pain and at least 1 lifestyle risk (overweight, poor diet, physical inactivity, and/or smoking), referred from hospital, general practice, and community settings. Statistical analysis was performed from January to December 2021.

Interventions

Participants were block randomized to the HeLP intervention (n = 174; 2 postrandomization exclusions) or guideline-based physiotherapy care (n = 172), stratified by body mass index, using a concealed function in REDCap. HeLP integrated healthy lifestyle support with guideline-based care using physiotherapy and dietetic consultations, educational resources, and telephone-based health coaching over 6 months.

Main Outcomes and Measures

The primary outcome was low back pain disability (Roland Morris Disability Questionnaire [RMDQ] score; 0-24 scale, where higher scores indicate greater disability) at 26 weeks. Secondary outcomes were weight, pain intensity, quality of life, and smoking. Analyses were performed by intention to treat. We estimated the complier average causal effect (CACE) as sensitivity analyses.

Results

The sample of 346 individuals (mean [SD] age, 50.2 [14.4] years; 190 female participants [55%]) had a baseline mean (SD) RMDQ score of 14.7 (5.4) in the intervention group and 14.0 (5.5) in the control group. At 26 weeks, the between-group difference in disability was -1.3 points (95% CI, -2.5 to -0.2 points; P = .03) favoring HeLP. CACE analysis revealed clinically meaningful benefits in disability among compliers, favoring HeLP (-5.4 points; 95% CI, -9.7 to -1.2 points; P = .01). HeLP participants lost more weight (-1.6 kg; 95% CI, -3.2 to -0.0 kg; P = .049) and had greater improvement in quality of life (physical functioning score; 1.8, 95% CI, 0.1-3.4; P = .04) than control participants.

Conclusions and Relevance

Combining healthy lifestyle management with guideline-based care for chronic low back pain led to small improvements in disability, weight, and quality of life compared with guideline-based care alone, without additional harm. Targeting lifestyle risks in the management of chronic low back pain may be considered safe and may offer small additional health benefits beyond current guideline-based care.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12617001288314.

Use of Intervention Mapping to Adapt a Psychologically Informed Physical Therapy Telerehabilitation Intervention for Latino Persons With Chronic Spine Pain

The need for culturally tailored pain care is well-recognized, yet few studies report how existing interventions can be adapted to the needs of culturally and linguistically diverse populations. This report describes a formative mixed-methods approach using intervention mapping-adapt and the expanded framework for reporting adaptations and modifications to evidence-based interventions to adapt and report modifications of an existing physical therapy intervention for Latino persons with chronic spine pain in Federally Qualified Health clinics in the southwestern United States. Mixed methods included literature reviews, patient surveys, an Adaptation Advisory Panel, and sequential case series with semistructured interviews. Six steps of intervention mapping-adapt guided the adaptation process and adaptations were prospectively documented with framework for reporting adaptations and modifications to evidence-based interventions. A needs assessment revealed an absence of culturally tailored physical therapy interventions for Latino persons with chronic spine pain in the United States. An intervention logic model and review of the sociocultural context guided the selection of essential interventions, determinants of behavior change, and outcomes. An existing cognitive behavioral-based physical therapy telerehabilitation intervention was selected for adaptation based on accessibility and strong congruency with the logic model. An Adaptation Advisory Panel planned and evaluated iterative adaptations of the cognitive behavioral-based physical therapy intervention content, activities, delivery, materials, and design. The adapted Goal-Oriented Activity for Latino persons with Spine pain intervention aimed to reduce pain intensity and disability through patient-centered goal setting in physical and cognitive treatment domains. Sequential case series supported feasibility and acceptability of the adapted intervention in the target population. PERSPECTIVE: We describe adaptation and reporting of an evidence-based physical therapy intervention for a culturally and linguistically diverse population. Greater rigor and transparency using tools such as intervention mapping-adapt and framework for reporting adaptations and modifications to evidence-based interventions will accelerate efforts to reduce ethnic and racial disparities in pain rehabilitation.

The Oswestry Disability Index is not a good measure for low back pain in adolescents: A Rasch analysis of data from 200 people

OBJECTIVE

To evaluate the psychometric properties of the modified Oswestry Disability Index in adolescents with low back pain through Rasch analysis.

DESIGN

This is a psychometric study.

SETTING

Physical therapy clinics of a large pediatric hospital in Columbus, Ohio (United States).

SUBJECTS

Two hundred adolescent patients with low back pain (112 female, 15.4 ± 1.9 years old).

MAIN MEASURE

The modified Oswestry Disability Index.

RESULTS

The mean modified Oswestry Disability Index score was 17.1 ± 12.1, with scores ranging from 0 to 56 on the 100-point scale. The Rasch person reliability for the Oswestry Disability Index was 0.70, representing minimal acceptable person reliability. The Oswestry Disability Index demonstrated poor item spacing, hierarchy, and targeting of the adolescents' disability level (>1 logit between person mean and item mean). A significant misfit was observed in three of 10 items. There were significant issues with the functioning of responses on all items of the Oswestry Disability Index. Principal component analysis of residuals revealed a ratio of 5.3:1, demonstrating acceptable unidimensionality.

CONCLUSION

Due to multiple psychometric issues, the Oswestry Disability should not be used to assess disability in adolescents with low back pain. The Oswestry Disability Index significantly mistargets adolescent ability and only provides an acceptable assessment of the most disabled adolescents.

Nonpharmacological Spine Pain Management in Clinical Practice Guidelines: A Systematic Review Using AGREE II and AGREE-REX Tools

OBJECTIVE: To summarize the content and critically appraise the quality and applicability of recent clinical practice guidelines (CPGs) for nonpharmacological, nonsurgical management of spine pain. DESIGN: Systematic review of CPGs. LITERATURE SEARCH: Six databases and seven guideline clearinghouses. STUDY SELECTION CRITERIA: Included de novo CPGs for nonpharmacological, nonsurgical management of spine pain designed for any primary health care providers, published in English, Arabic, French, or traditional Chinese within the past 12 years. DATA SYNTHESIS: Five reviewers independently appraised the guidelines using AGREE II and AGREE-REX. Interrater agreements were calculated for each domain and the total score of these tools using the intraclass correlation coefficient (2, 1) with absolute agreement. RESULTS: We included 30 CPGs, primarily (90%) developed in Western countries, which contained 404 recommendations. High-quality CPGs consistently recommended exercise therapy and multimodal care, encompassing a combination of exercises, mobilization/manipulation, education, alternative medicine, and cognitive-behavioral treatments. Generally, CPGs did not recommend assistive (eg, corsets and orthosis) devices or electro/thermotherapies (eg, therapeutic ultrasound and transcutaneous electrical nerve stimulation). Approximately half of the CPGs demonstrated good methodological quality according to AGREE II, whereas the rest were of poor quality. On the AGREE-REX assessment, one third of the recommendations were of excellent quality. CONCLUSION: Although recent guidelines frequently recommended exercise therapy and multimodal care for the management of spine pain, their recommendations often overlooked demographics and comorbidities. Despite methodological improvements, most CPGs lacked simple clinical applicability and considerations of knowledge users' values. J Orthop Sports Phys Ther 2025;55(1):1-14. Epub 4 November 2024. doi:10.2519/jospt.2024.12729.

An e-learning program improves low back pain beliefs of physiotherapists: a randomised trial

QUESTION

How effective is an e-learning program based on international clinical guidelines in promoting beliefs more aligned with the current evidence for the management of low back pain among physiotherapists?

DESIGN

Randomised controlled trial with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

106 physiotherapists who treat patients with low back pain.

INTERVENTIONS

The experimental group received access to an e-learning program, based on recommendations of clinical practice guidelines for the management of low back pain, over a 6-week period. The program consisted of six units, totalling 15 hours, and was offered in a self-instructional and self-paced format. The control group was instructed to continue their activities as usual.

OUTCOME MEASURES

The primary outcome was beliefs about low back pain measured using the Modified Back Beliefs Questionnaire (MBBQ, -50 worst to 50 best). Secondary outcomes included the Back Pain Attitudes Questionnaire (Back-PAQ, -20 worst to 20 best) and agreement with two statements (1: X-rays or scans are necessary to get the best medical care for low back pain; 2: Everyone with low back pain should have spine imaging). Participants were evaluated at baseline and 6 weeks.

RESULTS

Out of 53 participants allocated to the e-learning program, two completed only the first unit and one did not complete any units, resulting in an overall adherence rate of 94%. Compared with control, the e-learning program improved the MBBQ (MD 8 points, 95% CI 5 to 10) and the Back-PAQ score (MD 3.1 points, 95% CI 1.8 to 4.3). For the imaging beliefs statements, the e-learning program was able to increase the proportion of participants with beliefs aligned with the current evidence (statement 1: RD 38%, 95% CI 21 to 52; statement 2: RD 17%, 95% CI 7 to 29) compared with the control group.

CONCLUSION

The e-learning program based on recommendations of clinical practice guidelines for the management of low back pain improved physiotherapists' beliefs about the management of low back pain.

REGISTRATION

NCT05661968.

Lumbar spine coronal balance parameters as a predictor of rehabilitation management outcomes in patients with radiculopathy due to lumbar disc herniation: A multicenter prospective case series study

This prospective consecutive case series was conducted in 5 physiotherapy clinics in the UAE from January 2021-March 2023 to assess coronal lumbar spine radiographic parameters as a predictor of conservative therapy outcomes in patients suffering from low back and leg pain due to lumbar herniated nucleus pulposus (HNP). Ninety patients (mean age 44 yrs., 54 % male) with lumbar HNP underwent conservative therapy. All participants received lumbar spine MRI and radiography to assess spine alignment. Interventions included specific exercises, diathermy, traction, education, a home-based exercise program, and medications. Detailed demographic data was collected. Follow-up was 6-months after discharge. A successful outcome was based on a minimum of the following four outcomes: (1) reduction of radicular or leg pain by 17.5 points (0-100 NRS); (2) fatigue reduction by 7.5 points; (3) distress reduction by 5 points; and (4) interference reduction by 9.5 points. At 6-month follow-up, it was found that patient age, education, and radiographic lumbosacral angle measures significantly affected the odds of a successful outcome. Increasing age by 1-year significantly decreased the odds of success of improving pain (OR = 0.85, p = 0.016), fatigue (OR = 0.85, p = 0.016) and interference scores (OR = 0.89, p = 0.042) by 15 %, 15 % and 11 %, respectively. Lower education significantly increased the odds of success for improving pain, fatigue, and interference by 26.18, 26.18, and 7.5 (p = 0.006, = 0.006, and = 0.029, respectively). Increasing (worsening) the radiographic lumbosacral angle by each degree significantly reduced the odds of success for improving pain, fatigue, distress, and interference by 3.52, 3.52, 27.99 and 2.55, respectively (p < 0.001, <0.001, = 0.003, = 0.001). Our findings indicate that younger age, less education, and better coronal radiological lumbar spine alignment all had a substantial impact on the likelihood of success on 6-month outcomes in patients suffering from chronic lower back pain and radiculopathy due to HNP.

Quality of lumbar paraspinal muscles in patients with chronic low back pain and its relationship to pain duration, pain intensity, and quality of life

OBJECTIVES

To examine the relationship between the quality of paraspinal muscles and pain intensity, duration, and quality of life in patients with chronic low back pain (cLBP).

METHODS

Between January 2022 and December 2023, 119 individuals with no-back pain (no-BP) and 136 cLBP patients were enrolled. Both groups underwent health surveys and magnetic resonance imaging. Cross-sectional area (CSA), functional cross-sectional area (FCSA), and fat infiltration (FI) of multifidus (MF) and erector spinae (ES) were measured. Data were analyzed using multiple linear and binary logistic regression.

RESULTS

Compared to the cLBP group, the no-BP group had smaller CSA influenced by FI of ES at L5/S1 (p = 0.01), higher FCSA of ES (p < 0.01) at L4/L5, and lower FI of ES and MF at L4/L5 and L5/S1 (p < 0.01). CSA, FCSA, and FI showed no significant correlation with cLBP intensity except for the CSA (p = 0.02) and FCSA (p = 0.03) of the L2/3 MF. Pain duration positively correlated with FI at L2/3, L3/4, and L4/5 of MF and ES (p < 0.05) and CSA of the L1/2 MF (p = 0.02). CSA (L3/4, L4/5, and L5/S1) and FCSA (L4/5, L5/S1) of MF correlated positively with SF36 scores (p < 0.05), while ES muscles did not (p > 0.05). FI of MF and ES showed no correlation with SF36 scores.

CONCLUSION

CSA and FI were significantly higher, and FCSA significantly lower in paraspinal muscles of cLBP patients compared to asymptomatic participants. Increased FI correlated with prolonged cLBP duration, indicating FI and FCSA alterations may play a significant role in cLBP development and duration.

KEY POINTS

Question What is the relationship between paraspinal muscle quality and cLBP, including its intensity, duration, and impact on quality of life? Findings cLBP patients had increased FI and reduced functional muscle area in paraspinal muscles, with FI correlating with prolonged pain duration. Clinical relevance Understanding the changes in lumbar paraspinal muscles provides insight into cLBP progression, guiding personalized interventions to improve pain management and patient quality of life.

Negative back beliefs are associated with increased odds of low back pain and disability: a 10-year cohort study in men

OBJECTIVE

Although negative back beliefs are associated with high-intensity low back pain (LBP)/disability, whether they influence incident high-intensity LBP/high disability over the long-term is unknown. This study aimed to investigate whether negative back beliefs were associated with developing high-intensity LBP and/or high disability over 10 years in men.

METHODS

Men with no or low-intensity LBP and/or disability attending the Geelong Osteoporosis Study between 2006 and 2010 were included. Data on age, body mass index, mobility, education, back beliefs (Back Beliefs Questionnaire), LBP and disability (Graded Chronic Pain Scale) were collected between 2006 and 2010. Beliefs, LBP and disability were re-assessed in 2016-2021. Binary logistic regression was used to examine the association between negative back beliefs and incident high-intensity pain and/or high disability, adjusting for age, body mass index, mobility and education.

RESULTS

At baseline, 705 participants (mean age 53.8 years) had no or low LBP and no or low disability; 441 (62.6%) participants completed a 10-year follow-up. Of these, 37 (8.4%) developed high-intensity pain and/or high disability. In multivariate analyses, participants with more negative back beliefs at baseline were more likely to develop high-intensity pain and/or high disability (odds ratio 1.05; 95% CI: 1.00, 1.11). Developing more negative back beliefs was also associated with incident high-intensity pain and/or high disability (odds ratio 1.20; 95% CI: 1.12, 1.30).

CONCLUSION

In a male community-based population, negative beliefs regarding the consequences of LBP were associated with an increased likelihood of developing high-intensity pain and/or high disability. Addressing negative back beliefs in the community may reduce the incidence of high-intensity pain and/or high disability over 10 years in men.

Assessing the transparency in reporting of clinical trials investigating manual therapy interventions for low back pain: A methodological review

RATIONALE

Low back pain (LBP) is a common condition with a significant societal burden. Manual therapy is an effective treatment for LBP and recommended in clinical practice guidelines. While the quantity of literature supporting the use of manual therapy is large, the methodological quality and transparency of this collective work are unclear.

AIMS AND OBJECTIVES

Explore the transparency in reporting of clinical trials assessing manual therapy interventions in patients with LBP by comparing planned components in the trial registration with what was reported in the published manuscript.

METHODS

Three databases were searched to identify trials assessing the treatment effect of manual therapy for LBP from January 2005 to May 2023. Studies were included if the manual therapy consisted of thrust manipulations, mobilizations or muscle energy techniques.

RESULTS

From 4462 studies initially identified, 167 studies remained in the final review after title, abstract and full-text review. Only 87 (52.1%) of the 167 studies were registered (n = 57 prospectively and n = 30 retrospectively). Primary outcomes in the publications were identical to the registration in 54 (62.1%) of the registered trials. Secondary outcomes in the publication were identical to the registration in 27 (31.0%) of the registered trials. The CONSORT reporting guideline was referenced in only 19 (21.8%) trials. Multiple discrepancies between registration and publication were noted for primary and secondary outcomes. All trials had eligibility criteria in the registration that matched their corresponding manuscript, while only four (4.6%) trial registrations addressed any type of statistical analysis plan.

CONCLUSION

Approximately half of the trials were not registered. Of those registered, only half were registered prospectively. Substantial discrepancies existed between registered and published outcomes that were never addressed by the authors, raising questions about potential bias. Transparency can be improved through more stringent requirements during manuscript submission to journals, and better reporting of the rationale for discrepancies between registration and publication.

A multicenter feasibility randomized controlled trial using a virtual reality application of pain neuroscience education for adults with chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) is a highly prevalent condition among adults and is correlated to high levels of pain, high disability, and lower quality of life. Pain neuroscience education (PNE) helps to explain the pain experience and can affect psychosocial factors, such as fear of movement, anxiety, socioeconomic status, work life satisfaction, etc. More recently, virtual reality (VR) programs have emerged allowing for immersive PNE experiences.

OBJECTIVE

The purpose of this randomized clinical trial is to determine the feasibility of using a VR application for the delivery of immersive PNE (VR-PNE) and other activity training for patients with CLBP presenting to outpatient physical therapy (PT) clinics.

METHODS

A two-arm, parallel group, randomized controlled feasibility trial of patients was conducted at 12 outpatient PT clinics from March 9, 2022, through September 9, 2022. The intervention group received PT as usual and VR-PNE while the control group received PT as usual. Between group feasibility, acceptability outcomes and other patient-reported outcomes were assessed at six weeks.

RESULTS

A total of 595 individuals were evaluated for low back pain during the recruitment period. Seventy individuals were eligible and met definition for CLBP, 52 enrolled and 32 completed the trial. Participant adherence was 63.6% for VR-PNE and 63.2% for PT as usual. Participants found VR-PNE acceptable and reported satisfaction scores (0-100) of 87.37 ± 11.05 compared to 81.17 ± 23.72 in the PT as usual group. There were no significant differences between groups for the BBQ, BRS, FABQ-PA, FABQ-W, GROC, NPRS, NPQ, PCS, and PSEQ at 6 weeks.

CONCLUSION

The results of the trial suggest that VR-PNE may be acceptable and feasible for patients with CLBP. Study procedures and PT delivery modifications should be considered for the next iteration of this study to improve follow-up assessment rates.

Factors associated with participation in a walking intervention for veterans who smoke and have chronic pain

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720-3550] (sedentary) (n = 65), 7307 [IQR: 5952-8533] (not sedentary) (n = 24), and 3196 [IQR: 2237-5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation.Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016.

Early physiotherapy referral for low back pain reduces healthcare utilisation for advanced imaging and specialist spine surgery consultations

INTRODUCTION

Low back pain (LBP) is one of the most common presenting complaints among patients and the costliest orthopaedic condition. This study aimed to compare the healthcare utilisation rates of advanced imaging and specialist consultations for LBP between patients presenting with early physiotherapy (EPT) before specialist review and routine physiotherapy (RPT) after specialist review.

METHODS

Consecutive patients who (n = 311) had been referred to specialist spine surgery for LBP in 2021 were retrospectively reviewed. Baseline demographics, healthcare utilisation rates and clinical outcomes were compared between those who attended EPT before spine surgery consultation and those who attended RPT after specialist consultation.

RESULTS

There were no significant differences in baseline demographics or clinical outcomes of Visual Analogue Scale pain scores, EuroQol 5-Dimension scores and surgery rates between the EPT (n = 183) and RPT (n = 128) groups. At 6 months follow-up, EPT was associated with significantly lower magnetic resonance imaging (MRI) rates (P = 0.026), decreased likelihood of requiring MRI (odds ratio [OR] 0.865, 95% confidence interval [CI] 0.757-0.990), reduced number of specialist spine surgery consultations (P < 0.001), decreased likelihood of requiring additional specialist consultations (OR 0.770, 95% CI 0.655-0.905), fewer physiotherapy sessions (P = 0.001) and decreased likelihood of requiring additional physiotherapy sessions (OR 0.835, 95% CI 0.553-1.261).

CONCLUSIONS

Early physiotherapy reduces the (a) overall treatment duration from the first referral by the primary physician, (b) number of advanced imaging ordered (and thus, associated imaging costs), and (c) total number of clinic and therapy sessions, and it is safe and allows patients to achieve comparable functional outcomes to their counterparts undergoing RPT. These findings support the implementation of EPT for patients with LBP to reduce healthcare utilisation and associated costs for patients, providers and healthcare systems.

Multimodal intervention based on physical exercise, mindfulness, behaviour change and education to improve pain and health in patients with chronic primary low back pain: a study protocol of the HEALTHYBACK randomised controlled trial

The HEALTHYBACK trial is based on a multimodal intervention to determine the effectiveness of a supervised physical exercise, mindfulness, behaviour change and pain neuroscience education programme on several health variables in individuals with chronic primary low back pain (CPLBP). The study will be a randomised controlled trial among 70 individuals diagnosed with CPLBP (aged 18-65 years). The intervention will be conducted in person within a hospital setting for 16 weeks and comprises a first phase (16 sessions supervised physical exercise (2 days/week, 45 min/session), mindfulness (1 day/week, 2.5 hours/session), behaviour change (daily/24 hours via a wrist-worn activity prompting device) and pain neuroscience education (1 day/biweekly, 2 hours/session)) and a second phase (16 sessions functional full-body muscle strengthening exercise, 3 days/week, 50 min/session). The primary outcomes will include perceived acute pain, pain pressure threshold, conditioned pain modulation, temporal summation of pain and disability due to pain. Secondary measures will include physical fitness, body composition, gait parameters, device-measured physical activity and sedentary behaviour, haematological profile, self-reported sedentary behaviour, quality of life, pain catastrophising, mental health, sleep duration and quality, and symptoms related to central sensitisation. The groups will undergo pretest (before the intervention), post-test (after each phase of the intervention) and retest (at a 6-week detraining period after the intervention) measurements. The results will determine the effectiveness of multidimensional interventions on several health parameters in individuals with CPLBP. They will provide knowledge for pain management and functioning in affected individuals, which might diminish the need for primary healthcare services. Trial registration number: NCT06114264.

Effects of pain neuroscience education combined with neuromuscular exercises on pain, functional disability and psychological factors in chronic low back pain: A study protocol for a single-blind randomized controlled trial

OBJECTIVE

Chronic low back pain (CLBP) is a prevalent health condition worldwide. Several therapeutic interventions aim to improve CLBP. Pain Neuroscience Education (PNE) helps patients better understand their pain from biological and physiological perspectives, which clinicians use to reduce pain and disability in patients with chronic musculoskeletal conditions. Neuromuscular exercises (NMS) are also treatments adopted in CLBP. This study will investigate whether PNE combined with an NMS program improves pain, functional and psychological outcomes more than NMS alone in patients with CLBP.

METHODS

In this single-blind randomized controlled trial, 60 patients (male and female; age range, 30-60 years) diagnosed with CLBP will be randomly assigned to one of the following groups: (1) PNE plus NMS (n = 30; 24 sessions of PNE plus NMS in a total of 8 weeks, 3 each week), and (2) NMS alone (n = 30; 24 sessions of NMS sessions in a total of 8 weeks, 3 each week). Outcome assessors will be blinded to the group allocation. The primary outcome will be pain. Secondary outcomes will be disability, fear-avoidance beliefs about work and physical activity, self-efficacy, exercise anxiety, and kinesiophobia. Outcomes will be assessed at baseline, after 8 weeks of intervention, and 6 months post-intervention.

DISCUSSION

The findings of this RCT will help shed light on new treatment strategies to address the biopsychosocial dimensions of CLBP. The study protocol will be conducted in a clinical setting, offering the opportunity for future implementation in healthcare systems. Moreover, it will help clarify whether a combined treatment (PNE with NMS) is more effective than NMS alone for improving pain, functional and psychological outcomes in CLBP.

TRIAL REGISTRATION

Study registration: The study was prospectively registered in the Iranian Registry of Clinical Trials-IRCT20190427043384N2 (https://www.irct.ir/trial/69146). Registered on March 17, 2023.