What is the effect of low back pain self-management interventions with exercise components added? A systematic review with meta-analysis

BACKGROUND

Best practice guidelines endorse self-management and exercise in chronic low back pain (CLBP) management. The majority of existing self-management interventions (SMIs) do not include exercise components, and the effect of SMIs with exercises on CLBP and disability remains unclear.

OBJECTIVES

To systematically review the evidence for the effect of SMIs with an exercise component added, on pain and disability in people with CLBP.

DESIGN

Systematic review with meta-analysis.

METHOD

An electronic search of randomized controlled trials (RCTs) with SMIs with exercises was performed in 5 databases. Standardised Mean Difference (SMD) and 95% confidence interval (CI) were calculated using a random-effects model for meta-analysis at short-term, intermediate, and long-term follow-up points. The level of evidence was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

09 RCTs were included in the review and the GRADE quality assessment revealed low-quality evidence for all meta-analyses across 3 follow-up points. Effect sizes (ESs) for pain were -0.28, -0.36 and -0.21 for short-term, intermediate, and long-term respectively, and -0.30, -0.25 and -0.20 for short-term, intermediate, and long-term for disability, respectively. 6 out of 09 studies included tailored exercise programmes and exercise components differed widely in their content and delivery.

CONCLUSIONS

There is low-quality evidence that SMIs with exercises added have moderately positive effects on pain and disability in patients with CLBP compared to control interventions involving usual care, typically consisting of access to medication, exercise, advice, education, and manual therapy.

Effect of one session of mirror therapy on phantom limb pain and recognition of limb laterality in military traumatic lower limb amputees: a pilot study

Up to 70 % of military amputees suffer phantom limb pain (PLP), which is difficult to treat. PLP has been attributed to cortical reorganisation and associated with impaired laterality. Repeated sessions of mirror therapy (MT) can benefit PLP; however, anecdotal evidence suggests one MT session could be effective. In a one-group pretest and post-test design, 16 UK military unilateral lower limb amputees (median age: 31.0, 95% CI 25.0 to 36.8 years) undertook one 10 min MT session. Visual analogue scale (VAS) pain and laterality (accuracy and reaction time) measurements were taken pre-MT and post-MT. Median VAS PLP did not differ significantly between pre-MT 15 mm (2-53 mm) and post-MT 12 mm (1-31) (p=0.875) scores. For the amputated limb, there were no significant differences between pre-MT and post-MT scores for laterality accuracy, 95.3%, 95% CI 90.5% to 97.6% and 96.7%, 95% CI 90.0% to 99.4%, respectively (p=0.778), or reaction time, 1.42 s, 95% CI 1.11 to 2.11 s and 1.42 s, 95% CI 1.08 to 2.02 s, respectively (p=0.629). Laterality was also not different between limbs for accuracy, p=0.484, or reaction time, p=0.716, and did not correlate with PLP severity. No confounding variables predicted individual responses to MT. Therefore, one 10 min MT session does not affect laterality and is not effective as standard treatment for PLP in military lower limb amputees. However, substantial PLP improvement for one individual and resolution of a stuck phantom limb for another infers that MT may benefit specific patients. No correlation found between PLP and laterality implies associated cortical reorganisation may not be the main driver for PLP. Further research, including neuroimaging, is needed to help clinicians effectively target PLP.

A novel objective classification method to discriminate and monitor recovery in subgroups of chronic low back pain

Background:

The heterogeneity of chronic low back pain (CLBP) can be deleterious to its successful management. Classification systems (CSs) that subclassify CLBP in order to target treatments rely on clinical judgement; therefore, less subjective classification is preferable. This study aims to determine whether the Cardiff Classifier (CC), which is an objective classification system based on Dempster-Shafer theory can discriminate between CLBP subgroups on the basis of spinal-pelvic repositioning errors (RE), and establish the most sensitive parameters for discriminating subgroups of CLBP and predicting recovery.

Methods:

Baseline and post-motor learning intervention (MLI) REs from 87 CLBP individuals with flexion (FP, n=50); passive extension (PEP, n=14); and active extension (AEP, n=23) pattern disorder (subclassified by a clinical multi-dimensional CS); and REs from 31 healthy (H) participants were recorded. These REs were inputted into the CC to provide objective and visual indicators of CLBP subgroups and MLI effect. REs were transformed into a set of three belief values: healthy (H); CLBP; and uncertainty. Each participant's status was visually represented as a single point in a simplex plot. Participants on the left of the central line were considered healthy and those on the right of it were considered to have CLBP characteristics.

Results:

The CC's accuracy in discriminating between: FP and H was 85.2%; AEP and H was 96.3%; and PEP and H was 100%. Combining all CLBP reduced the CC's accuracy to 68.6%. The most distinguishing parameter for FP was sitting lumbar RE, and for AEP/PEP it was standing lumbar RE. CC distinguished pre- and post-intervention REs with 85.7% accuracy for FP and 90% for AEP with respective sitting lumbar and standing pelvic RE as the most sensitive predictors of recovery.

Conclusions:

This is the first application of CC in CLBP. The CC accurately discerned three clinical CLBP subgroups and identified parameters that most accurately characterise each subgroup and best predict post-intervention recovery. The CC enhanced classification accuracy to discern between CLBP and H when patients were subclassified. CC should be further tested using clinical classification data.

Implications:

CLBP classification is a complex process requiring high level clinical expertise to synthesize a unique set of physical/clinical characteristics in each CLBP person. The CC can order complex data sets to aid clinicians’ interpretation to target therapy and identify the most sensitive parameters for monitoring recovery thus enhancing classification robustness.